Mindfulness in Psyhotherapy

Vladimir Bostanov, PhD

(The article was printed in the hOUR THERAPY bulletin in 2024)

We are unaware or partially aware of most of what we do. When we walk down the street, we are not aware of the complex movements our body makes in order to keep its balance and move forward. Driving a car, we barely notice the movements of our hands and feet, and, if we are on a familiar route and lost in thought, we might even be unaware of the turns we make on the road, in order to reach our destination.

The number of our daily unconscious actions is virtually infinite. But what about our mental activities? Lets make a little experiment:

John was on his way to school.

He was worried about the math lesson.

He was not sure he could control the class again today.

It was not part of a janitor’s duty.

Reading the first two sentences, we unconsciously imply that John is a student (since this is, statistically, the most probable case). After the third sentence, we conclude — may be with some conscious awareness but still automatically — that he is a teacher. The fourth sentence confuses us ("Why is the janitor in charge of the class?"), before we realize that someone is playing a trick on us. But it also gives us an opportunity to become aware of the interpretations performed automatically by our mind. If we are mindful, we might even realize, how our mind instantly created a little scenario while reading: "He is worried, obviously unprepared, fears having a test, and getting a bad grade.". We might even mindfully notice the slight nauseous sensation in our stomach, caused by feelings of anxiety and helplessness, triggered by an automatic association with the school problems of our own child, who has been getting progressively lower grades lately, thus "ruining his/her own future"...

Our brain's ability to process situations unconsciously, interpreting them by applying learned associations and schemes, is a huge advantage. It enables our conscious mind to focus on problems that cannot be solved unconsciously, e.g., the careful planning of our next day at work. Besides utility, our safety makes a lot of automatic, unconscious reactions critically important. In a potentially dangerous natural environment, it would be safer if an alarming noise in the bush triggered the scheme "predator attack" and the according automatic reaction — fight or flight — even though it might eventually turn out to be just some harmless bird.

There are, however, unconscious processes and cognitive schemes that could be dysfunctional, destructive, and even fatal for our mental (and physical) health. Consider, e.g., automatic thoughts like "He/she gave me a strange look. Obviously, he/she finds me ugly (or, fat, stupid, repulsive, etc.).", or "My school/work performance is bad. This means that I am a looser (moron, misfit, etc.).". Such misinterpretations, exaggerations, overgeneralizations, etc. are common in people prone to depression, and they often occur unconsciously. In such cases they have the greatest chance of triggering a depressive episode, because the afflicted person cannot question their accuracy — because the person does not know that their mind has "explained" the situation in this way, but they just feel uncomfortable; and they cannot even tell what this discomfort really is: whether it is sadness, or being ashamed, or feeling hurt, or lonely, helpless, hopeless, or something else.

It can be even harder to become aware of some core schemes and deep assumptions about oneself and the world like, e.g.: "I do not deserve to be loved, therefore, no one will ever love me."; or: "If I show my true feelings, he/she will inevitably hate/despise (or use/abuse/hurt) me.". Such dysfunctional schemes and attitudes are usually learned during childhood in the relationships with the most important persons in the child's life — parents or other significant figures. For this reason they are deeply ingrained, change-resistant, and very hard to even become consciously aware of.

Becoming aware of unconscious mental processes, feelings, needs, and drives has been an important concept in almost all schools of psychotherapy. It can be found in different forms in the different approaches. Before we discuss in more detail the role of mindful awareness in contemporary cognitive behavioral therapy (CBT), we will mention briefly the function of awareness in a few of the other most popular schools. Psychoanalysis is aimed at illuminating unconscious conflicts that cause the clients symptoms and suffering. The humanistic approaches help people to become aware of their deepest needs as well as the fears that block their personal growth, thus facilitating self-actualization and maximization of their full potential. In the words of Carl Rogers, the founder of person-centered counseling, the client becomes the person that he/she really is, starts being that person. Fritz Perls, the founder of gestalt therapy, emphasizes "... that this is the great thing to understand: that awareness per se — by and of itself — can be curative.“ (Fritz Perls)

The adoption of mindfulness as a concept and method in CBT is an interesting and exciting story. It is known as the "third wave" — after the behavioral and the cognitive. The original behavioral therapy was focused on the extinction of dysfunctional behaviors and the reinforcement of healthy ones. Fear of birds (or elevators, or social situations, etc.) is not innate, but acquired, i.e., learned, hence it can be unlearned (by exposure to the fear-inducing stimuli). Withdrawal from physical activity in depression can be overcome by learning new behaviors: taking a walk in spite of feeling tired and powerless, doing household chores despite fatigue, etc.

The second, cognitive, wave was heavily influenced by ancient Greek philosophy — by the teachings of Socrates, Epictetus, Marcus Aurelius, and other great minds. The main idea is that humans suffer not only from adverse circumstances and unfortunate events, but also from the way they interpret them; that a distorted perception of the environment causes even more suffering than objective phenomena like natural disasters, injuries, sickness, and death. Hence, by changing our attitudes and opinions, and the way we interpret events, we can overcome suffering. Panic attacks provide a vivid example. The suffering caused by them can be immense — we agonize, convinced that we are dying — while, in fact, our symptoms are caused by just fear, without any underlying medical condition, and thus pose no threat to our physical health. Another example is depression. Before the second wave, behavioral therapists believed that negative thoughts like, e.g., "nobody cares about me" or "I will always be alone" were just symptoms of depression. Cognitive therapists (Aaron Beck, Albert Ellis, and others), however, realized that such thoughts and beliefs can, and actually do trigger, maintain, and amplify depressed mood and all other symptoms of depression. Accordingly, cognitive therapy is focused on systematically changing negative thoughts, harmful beliefs, and dysfunctional attitudes. One of the techniques introduced by Beck, known as "Socratic questioning", facilitates a "guided discovery" which helps clients become aware of their own cognitive distortions.

The third wave was a result of the introduction of Buddhism to Western society. While the philosophy of ancient Greece and Rome has always been a traditional foundation of Western rationalism, the teachings of the Far East had been relatively unknown until the mid 20th century. One of the first things that impress those who are somewhat familiar with both traditions is the striking similarity between their concepts of suffering which in both schools of thought is conceived of as caused by our own (erroneous) attitudes about the world and our interpretations of events. But while Western philosophy tends to be more rational, the Eastern tradition has a more prominent contemplative (and thereby mystical) component which is deeply rooted in the meditation practices of Hinduism and Buddhism. Some of these practices were adopted with few changes by the third wave in CBT because of their empirically confirmed hight effectiveness in overcoming various kinds of suffering caused by anxiety, depression, addiction, etc.

Every kind of meditation includes at least two elements: concentration and mindfulness. It is the meditative, contemplative concentration that distinguishes the mindfulness practiced in CBT from the curative awareness processes typical of other schools of therapy. Through systematic meditation training, we learn to focus our attention with greater clarity and with less craving and aversion on our own thoughts, emotions, sensations, reactions and impulses. Thereby, we create favorable conditions for therapeutic insight. The quality and intensity of such insights can vary widely. Let us return to the example of panic attacks. After we have been given a convincing rational explanation (which we have understood and accepted) that these episodes do not pose any threat to our health, the panic attacks, nevertheless, continue to occur. We begin practicing mindfulness meditation. After a few weeks, during an acute panic attack, we manage to accept our fear, to monitor it, and to experience it mindfully. Then comes the insight that fear is not dangerous. Since experiential insight is much more profound and transformative than rational, intellectual knowledge, the panic attacks lose their power over us, decrease in frequency and intensity, and gradually (or suddenly) disappear from our life.

Here is a final example:

A woman who was sexually abused by close relatives as a teenager suffers from recurrent depression. She attends an eight-week course of mindfulness-based cognitive therapy (MBCT) and starts meditating on a daily basis. The next depressive episode comes. She fights it and manages to function and to do her high-responsibility job. Her desperation grows, however, and every morning she wonders whether she would be able to make it through the day, or whether, finally, the "total" breakdown would come. She starts thinking that meditation is useless and cannot help her anymore; but she does it anyway. One day, during meditation, she suddenly realizes that she is not guilty of the sexual abuse she suffered. Of course, she has always known that and has been rationally convinced of it. But, apparently, deep inside, there has been a conviction that she was to blame, that she was bad, doomed or some similar destructive belief. The insight that she gained during her meditation was a direct experience of the truth about her old trauma and that is why it had a long-lasting healing effect. (A slow but steady recovery from depression followed.)

Mindfulness meditation was introduced to western medicine and psychotherapy by persons like Jon Kabat-Zinn, Marsha Linehan, and the founders of MBCT, Mark Williams, John Teasdale, and Zindel Segal. One of their most important messages to professionals interested in mindfulness-based interventions is: In order to teach mindfulness, you must practice it yourself (preferably, on a daily basis), and you need substantial meditation experience, including some with a qualified teacher. Williams, Teasdale, and Segal described how they learned this the hard way, trying a "shortcut" without own practice, which brought them in confusing situations with clients they were instructing. Certainly, there is also an implicit message to clients here. If you decide to work with a professional offering a mindfulness-based intervention, ask them: what training have they completed, for how long and how often have they practiced meditation, have they attended an intensive meditation retreat?

The last message to those, making their first steps in mindfulness meditation is: Do not give up! Even though the first weeks might turn out to be more disappointing than encouraging; despite failing to understand "how it works" and what these strange exercises have to do with your problems, do not stop practicing 20 to 30 minutes every day. Usually, sooner or later, an insight will come that will help you start realizing — if not rationally, at least intuitively — how this approach may change your relationship to the world, to other people, and to yourself in a way that reduces suffering and brings more freedom in your life.

References:

• Jon Kabat-Zinn, Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness. Bantam; Revised edition, 2013.
• Mark Williams, John Teasdale, Zindel Segal, and Jon Kabat-Zinn, The Mindful Way through Depression: Freeing Yourself from Chronic Unhappiness. The Guilford Press; 2nd edition, 2024.
• Mark Williams and Danny Penman, Mindfulness: A Practical Guide to Finding Peace in a Frantic World. Piatkus Books, 2011.