Supplementary Notes for Mindfulness Skills in Clinical Practice

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Introduction to the science and practice of mindfulness

I. Why practice mindfulness?

a. Research findings

b. Clinical perspectives

i. Client-centered

ii. Clinician-centered

II. What is mindfulness?

a. Contemporary and classical perspectives

i. Relevance to clinical practice

b. Lessons from research and clinical practice

c. Essential elements of mindfulness

i. Intention

ii. Attention

iii. Present-centered awareness

iv. Acceptance

III. Intentionality of mindfulness

IV. Objects of attention

a. How can this process be applied in the treatment of psychological disorders?

V. Mindful attitudes beyond acceptance

VI. What acceptance is NOT

VII. Acceptance and client/clinician therapeutic rapport

VIII. The How of Mindfulness

a. Attitude

b. Body Posture

c. Concentration

i. The reciprocal relationship between mindfulness and concentration

ii. Meditating ‘with’ the breath

IX. Brief seated mindfulness practice

a. Integrating the essential elements of mindfulness

b. Application to facilitating clients and patients

X. Discussion

a. Challenges to practicing mindfulness

b. Normalizing distractibility can be helpful to clients who are new to this skill

c. The process of meditation as a metaphor for how life is lived

i. Acceptance vs. judgment

ii. Avoidance vs. approach

iii. Embattled vs. peaceful

Mindful Movement for Self-Regulation

I. Defining Mindful Movement

a. Key components

i. Postural alignment

ii. Muscular relaxation

iii. Breath awareness

iv. Intentional movement

v. Mindfulness: present-centered awareness focused upon the body and breath

II. Forms of Mindful Movement Practices

a. Yoga

b. Tai Chi Chuan (Taijiquan)

c. Qigong

d. Walking Meditation

e. Various forms, including the Feldenkrais Method, Pilates, and dance; movement that integrates the processes of intention and attention with attitudes that support mindfulness, including playfulness.

III. Defining Self-Regulation

a. “Self-regulation is the process whereby systems maintain stability of functioning and adaptability to change (Shapiro et al).”

b. “…the way the mind organizes its own functioning…fundamentally related to the modulation of emotion…(Dan Siegel).”

IV. Five Self-Regulation Skills Facilitated by Mindful Movement

V. Experiential practice of self-regulation skills through mindful stillness and movement

a. Applicability to clinical practice

b. Why incorporate mindful movement and mindful body awareness practices into treatment?

b. Mindful movement is a skill or intervention within the context of treatment, education, and mindfulness practice. As with any form of mindfulness practice, it applies to the client and the practitioner

VI. Assessing how to apply mindful movement and mindful body awareness practices in the treatment of psychological disorders

a. Points to consider

i. Patient interest and motivation

ii. Is the intervention in support of approaching or avoiding discomfort?

i. How do mindful movement and mindful body awareness practices align with therapeutic goals?

ii. In-session experiential practice vs. outside ‘homework’ tasks

1. It’s preferable to begin with guided in-session practice before ‘prescribing’ at-home practice sessions.

2. Assess client understanding of the connection between practice and therapeutic goals

VII. Mindful Movement: General Clinical Perspectives

a. Treatment and education of the whole person

b. Movement and body awareness practices access the body, mind,

i. and emotions in support of self-regulation, integration, nonreactivity,

ii. and deep relaxation.

c. Mindful movement can cultivate a sense of mastery and

i. competency.

d. This can be particularly relevant in the treatment of children.

e. Mindful Movement complements seated practice and provides many of the same benefits when practiced with a clear intention, focused attention, and integration of mindful attitudes (acceptance, non-striving, and openness come to mind).

f. Mindful movement can be framed and experienced as play, which is an alternative to the work, pain, struggle, challenge, and fight frames associated with various psychological and medical treatments.

VIII. Mindful Movement Cultivates

a. Somatic resourcefulness (i.e., using the body to create a sense of internal support)

b. Attention

c. The embodiment of intention, attention, acceptance, stability, and adaptability

d. Support for physical health, wellbeing, mood, and quality of life

i. Self-regulation

IX. The ethics, limitations, and boundaries of apply mindfulness, mindful movement, and mindful body awareness practices in a clinical setting

a. Professional competency, ethics, and boundaries

b. Discussion

i. How are you currently applying any of these practices?

ii. How might these practices support your clinical efficacy?

X. Current Research Findings

a. Physical/Medical

b. Psychological

c. Neurological

XI. Symptom reduction vs. eliminating suffering

i. Relevance to Acceptance and Commitment Therapy

XII. Discussion: How do mindfulness and mindful body-awareness practices support the delivery of clinical services?

a. How to embody intention and attention

b. How to embody qualities that enhance treatment effectiveness and client receptivity (e.g., empathy, warmth, respect, genuineness, acceptance, and encouragement)

c. How to manage stress and energy levels

d. Enhanced awareness of body posture and speech

XIII. Mindful Movement Practice

a. Integrating intention, attention, and mindful attitudes into the practice

b. Mind, Body, and Breath Regulation

i. Breath as a bridge between body and mind

ii. Implications for self-regulation attention and mood

Beyond Meditation: Understanding the Philosophical and Ethical Foundations of the Practice

I. Mindfulness in Historical Context: 1/8 of a Path

a. Four Noble Truths

i. Suffering (or unsatisfactoriness/dissatisfaction)

ii. The cause of suffering

iii. The end of suffering

iv. The path that leads to the end of suffering

II. The Mental Discipline Dimension

a. Skillful Effort

b. Skillful Mindfulness

c. Skillful Concentration

d. How mental discipline supports mindfulness practice

i. Mindfulness in the clinician’s office vs. the client’s world

ii. Establishing a mindfulness practice

III. The Wisdom Dimension: Understanding the Nature of Mind and Reality (Skillful Understanding and Skillful Thinking)

a. Attachment

i. Psychoanalytic/Contemporary vs. Eastern/Ancient Perspectives

ii. The antidote to attachment is generosity/letting go

b. Aggression

i. Includes internal judgments and outer actions

ii. The antidote to aggression is loving-kindness

c. Ignorance

i. The antidote to ignorance is understanding

d. Habituation

e. Avoidance

f. Control

g. Conditioning

h. External attributions of cause

i. Insights from Jungian Psychoanalysis: Ego, Persona, and Shadow

j. Personal narratives and the formation of identity

IV. The Ethical Dimension

a. The dynamic between cultivation (e.g., prosocial actions) and restraint (e.g., from harmful actions)

b. Ethical precepts traditionally involve a commitment to abstain from:

i. Killing or causing harm to other living beings

ii. Stealing or taking what is not given

iii. Sexual misconduct

iv. Lying or gossiping

v. Using intoxicants that cloud the mind

c. Aligning with your intentions and values

i. Speech

ii. Action

iii. Livelihood

d. The Power of Community

i. Social support enhances clinical efficacy

V. Core orientations toward self, others, and the world that complement and extend the practice of mindfulness

i. Loving-Kindness

ii. Compassion

iii. Joy

iv. Equanimity

VI. Practice: Loving-Kindness Meditation

a. This is a method that complements other mindfulness practices and reinforces the attitudes that strengthen the usefulness of mindfulness. Applicability to treating anger, hostility, interpersonal problems (work stress and relationship stress), depression, self-esteem problems, victimization and consequences of trauma, guilt, and shame.

b. Debrief

VII. Classical teachings that correlate with contemporary findings from neuroscience and psychology

a. Impermanence

b. Suffering or Dissatisfaction

i. Avoidance and control

ii. Dopamine

iii. Elimination of suffering vs. elimination of symptoms (e.g., ACT)

c. Non-self

VIII. Behavioral change complements insightful understanding

a. Developing an understanding of the workings of the mind and integrating values work (e.g., ACT) can add to therapeutic efficacy

i. Mindful thinking, speaking, and acting in support of behavioral change

ii. Aligning with your intentions and values

1. Thoughts

2. Speech

3. Actions

IX. Remember: Mindfulness and insight can be used defensively

a. Dissociation and avoidance of discomfort vs. openness and approaching discomfort

b. Why approach discomfort?

X. The Power of Community

a. Social support supports psychological and physical health

b. Mindfulness in various contexts

i. Health and wellness

ii. Fitness

iii. Rehabilitation

iv. Spiritual and religious

Mindful Somatic Interventions for Cultivating Self-Regulation and Healing Stress, Trauma, and Pain: Mindfulness of the Body

I. Traditionally, Mindfulness of the Body is one of the four Foundations of Mindfulness (also including feelings, mind, and objects of mind)

a. Body Parts

b. Body Positions

i. Standing

ii. Walking

iii. Sitting

iv. Lying Down

c. Elements (space as mind/intention 5th element in some traditions)

i. Earth

ii. Air

iii. Fire

iv. Water

v. Note: Working with “elements” can be presented in a non-esoteric way that reference concrete somatic experiences as resources in alignment with treatment goals and client intentions

XIV. Perspectives on Mindful Movement and Mindful Body Awareness Practices in Mindfulness-Based Therapy

a. Mindful Movement and Mindful Body Awareness practices can be used as treatment interventions within therapeutic orientations such as Cognitive-Behavioral Therapy (CBT) and Acceptance and Commitment Therapy (ACT)

i. Know the rationale for using these practices

1. Defusion?

2. Desensitization?

3. Self-regulation?

b. View the body as a resource for healing, safety, and support

c. Simplicity is valued over complexity when introducing these practices

d. Know your patient/client!

XV. Principles of Mindful Body-Focused Interventions

a. Every individual has somatic resources that can be accessed under certain conditions.

b. Here-and-now experience is the primary focus of intervention

c. Distinctions between a ‘How’ (primacy of experience) vs. ‘Why’ (analysis of experience) orientation

d. Somatic resourcefulness can be taught and practiced.

e. Intentional connection is potentially stabilizing.

i. Connection can be internal and external

f. A relational connection is an external bridge to internal connection via a ‘safe container’.

g. ‘Being with’ aversive internal experiences is valued over diminishing, eliminating, or controlling these experiences.

XVI. Depression

a. Mindful movement as antidote to immobility

b. Mastery and competency as an antidote to low self-esteem (especially for younger patients)

c. Enhanced body awareness as a tool to overcome anhedonia by ‘waking up’ the body.

d. Incorporating movement to support self-compassion and kindness

XVII. Anxiety, Trauma, Psychophysiological, and Stress-Related Disorders

a. Mindful movement as a method of cultivating a harmonious

relationship to physical sensations: ‘flow’ vs ‘flight, fight, or freeze’.

b. For patients with Generalized Anxiety Disorder and to some extent OCD, mindful movement refocuses the over-ideation and worry upon bodily experience, with an attitude of acceptance.

c. For patients with PTSD and trauma-related symptoms, mindful movement can access a sense of ‘embodied’ security, stability, and support, and the present-centeredness of this form of movement can be an antidote to the dissociation and emotional numbing often experienced by these patients.

d. Enhanced wellness and quality of life

XVIII. Childhood and Adolescent Disorders

a. Mindful movement as a method of developing rapport through ‘play’ with young children.

b. Training in concentration for children and adolescents with ADHD.

c. Cultivation of various skills (assertion; cooperation) through the ‘play’ of mindful movement

XIX. Relationship Problems

a. Dyadic mindful movement exercises can be used in the context of couple’s therapy.

b. Timing, phase of treatment, psychological stability, level of hostility, and potential for abuse are factors to consider when incorporating this method.

XX. Schizophrenia

a. Mindful movement can be incorporated into treatment programs as well as the clinician’s office.

b. This form of movement reinforces healthy behavior through mild-moderate exercise and is much less anxiety-provoking than mindfulness interventions that incorporate stillness and/or close-eyed ‘formal’ meditations.

c. The patient and their level of functioning, not the diagnosis, will determine the appropriateness of this modality

XXI. Sexual Disorders

a. Enhanced body awareness can support behavioral interventions such as Sensate Focusing.

XXII. The Form and Focus of Mindful Movement and Mindful Body Awareness Interventions

a. Client-centered

i. Enhancement of health, wellness, and quality of life

ii. Reduction of symptoms and distress

iii. Decreased autonomic arousal

iv. Improved sleep

v. Reduced muscular tension

vi. Cultivation of specific skills related to treatment goals

1. Concentration

2. Self-compassion

3. Enhanced interoception

vii. Mindful movement is a form of mindfulness practice

viii. Mindful movement is facilitative of the therapeutic process

b. Clinician-Centered

i. Embodiment of intention and attention

ii. Embodiment of therapeutic factors (empathy, warmth, respect, genuineness, acceptance, encouragement)

iii. Enhancement of therapeutic alliance through ‘joining’ the client’s style

iv. Authenticity

1. Mindfulness of the body as a ‘way of being’ or relating vs. a ‘strategy’ that is attached to an outcome

v. Stress and energy Management

XXIII. Body-Centered Mindfulness Practice

a. Debrief following the practice

b. Applicability to Anxiety, Trauma, and Stress-Related Disorders

XXIV. Therapeutic Paradoxes of Focusing on Aversive Physical Experiences

a. Process vs. Progress

b. Acceptance and Willingness

i. Pain + Resistance = Suffering

XXV. A Key Principle of Mindfulness-Based Treatment of Trauma and Pain

a. Moving toward the discomfort, with acceptance and compassion

i. An antidote to the common reinforcing strategies of avoidance and control

XXVI. Mindfulness of the Body Benefits the Therapeutic Relationship

a. Attunement

b. Resonance and Emotional Contagion

i. In a therapeutic relationship, influence is a bilateral mind-body phenomenon

ii. Mindful influence is respectful, skillful influence

XXVII. Mindful Body Awareness Skills and Practices

a. Body Awareness Interventions

i. Body Scan

ii. Mindfulness-Based Relaxation

iii. Body-Focused Inquiry

b. Integration work

i. Embodiment

ii. Dyadic practices

iii. Working with psychological and emotional polarities (e.g., aggression and gentleness)

XXVIII. Practice: Mindfulness-Based Relaxation

a. Post-practice discussion

b. Applicability in the treatment of Anxiety Disorders, Pain, Trauma, and Stress-Related Disorders

Mindfulness-Based Psychotherapy: Becoming a mindfulness-based clinician

I. Mindfulness-Based Psychotherapy: 3 Descriptive Perspectives (Pollak, Pedulla, and Siegel, 2014)

a. The Mindful Therapist

b. Mindfulness-informed therapy

c. Mindfulness-based therapy

II. Mindfulness enhances therapeutic efficacy

a. Across different therapeutic modalities, there is little difference in outcome.

b. Common factors predict outcome.

c. Mindfulness practice explicitly cultivates qualities that enhance the therapeutic relationship

III. Essential ways of incorporating mindfulness into clinical practice

a. Formal meditation practice

b. Informal mindfulness practice

i. A way of being in everyday life (for clients and clinicians)

c. Interventions, skills, and attitudes that inform and guide the process of treatment

d. A way of looking deeply at self and other, mind/body/environment

IV. The Mindful Therapist

a. Mindfulness practice increases attention

i. Trains the mind to sustain attention and switch attentional focus

b. Mindfulness practice increases empathy

i. Empathy is more predictive of patient outcome than technique or theoretical orientation.

c. Increases Self-Compassion

i. Moment to moment analyses of videotaped interactions between therapist and client demonstrated that therapists who rate themselves as less compassionate toward themselves are less compassionate toward their clients.

a. Increases Affect-Tolerance

i. We experience emotions as transitory and can be received without fear. We can hold space for our patients’ emotions, modeling for them a new way of being with emotion.

ii. We create ‘space’ for the emotions, and they are then not overwhelming

d. Some research has focused on the effects of meditation on the therapist.

i. Pioneering study by Grepmair et al (2007) examined effects of therapist meditation practice on patient outcomes.

ii. Patients treated by meditating therapists improved significantly more than patients being treated by the non-meditating therapists, with fewer symptoms of anxiety, depression, hostility, somatization, and obsessions and compulsions.

V. Mindfulness-Informed Therapy

a. Therapy informed by insights derived from meditation, mindfulness practice, etc., without formally teaching meditation.

b. Books: Thoughts without a Thinker (Epstein); The Wise Heart (Kornfield); Sitting Together (Pollak et al); Mindfulness and Psychotherapy (Germer et al)

c. Impermanence

i. Suffering arises out of the mistaken view that things are permanent. We suffer not because things are impermanent but because we resist impermanence.

ii. The insight of impermanence can be liberating to clients and can be offered without teaching formal mindfulness practice.

iii. The therapist can provide examples

d. Non-Self

i. Teachings on impermanence extend to the understanding of the self. Everything changes, including the self. “When you look deeply into the river of yourself, there is nothing to hold on to, nothing permanent and unchanging from moment to moment.” (Dr. Thomas Bien)

ii. In a clinical setting we can invite a wholehearted inquiry into “Who am I”, allowing the client to step outside the egocentric perspective and see that this fixed entity that we are constantly protecting and defending does not really exist, at least not into the way we think.

iii. We inquire: “Am I this body?” Am I the skin, the hair, the muscles and bones, or the organs? Am I this stream of every-changing emotions, thoughts, ideas, and beliefs? If not, who am I?

e. Accepting What Is

i. Mindfulness offers the insight that suffering arises when we resist what is:

ii. Suffering = Pain x Resistance

iii. Mindfulness offers a way of openly relating to all of experience. We face and embrace everything that arises, instead of resisting or running away from it.

iv. How we relate to pain determines how much we suffer

v. Pain is inevitable, but suffering is optional

vi. R.A.I.N. (Acronym first coined by Michele McDonald and used prominenty by Shapiro and Brach)

1. Recognizing what is here

2. Allowing and accepting it

3. Investigate it with intimate Attention

4. Not-identified awareness, reperceiving (resting in natural awareness or true nature)

VI. Working with Thinking

a. Do not believe your thoughts!

b. Your thoughts are not YOU.

c. Thoughts are recognized as impermanent.

d. Bow to them. “Thank you for your opinion”.

e. Inquiry (T. Brach, B. Katie):

i. What is it like to believe this thought?

ii. Is this thought absolutely true?

iii. What am I getting out of believing this thought?

iv. Who would I be if I didn’t believe it?

VII. True Nature

a. Mindfulness offers an approach that assures that our true nature is pure and virtuous and deeply loveable. No matter the circumstances, everyone shares an inherent goodness of heart that is available in any moment. (e.g., “basic goodness”/Shambhala teachings of Chogyam Trungpa, Pema Chodron)

b. An antidote to identifying with our thoughts and judgments.

c. To paraphrase T.N. Hanh, “mindfulness is love” and “when we are mindful, we are happy”.

d. Mindfulness of self, other, and the world: “raw experience without the ‘story’ attached to it”. What does that mean and how can we apply that to therapy with our clients and patients?

VIII. Therapies incorporating Mindfulness

a. Mindfulness-Based Stress Reduction (Kabat-Zinn)

i. Stress, pain, adjustment to major illnesses, quality of life

b. Mindfulness-Based Cognitive Therapy Teasdale, Williams, et al in UK

i. Relapse prevention in depressive disorders

c. Mindfulness-Based treatment for Insomnia (Ong, Shapiro, Manber, 2007)

d. Mindfulness-Based Relationship Enhancement (Carson et al)

e. Mindfulness-EAT for Binge Eating (Kristeller)

f. Individual therapy, without a manualized intervention

g. DBT

i. mood and personality disorders

h. ACT

i. wide range of populations, including anxiety, depression, substance abuse, and psychotic disorders

i. Much work is being done with how we can use mindfulness with children.

i. ADHD

IX. Mindfulness and Health Care Professionals

a. Decreases stress

b. Increased quality of life

c. Increased empathy and compassion

d. Negative effects of stress (importance of self-care for the therapist)

e. Literal & metaphorical truth: “The heart pumps blood to itself first before pumping blood to the rest of the body.” (Shapiro)

X. Experiential Exercises

i. Walking meditation

1. Why walking might be more accessible to some clinical populations

ii. Sitting meditation

1. Concentration

a. Focused attention

2. Mindfulness

a. Open monitoring

XI. Clinical Matters

a. Prevention of adverse effects associated with mindfulness meditation

b. Fitting the practice to the client

i. Choice points

c. Educational vs. experiential approaches

d. Facilitating mindfulness practices

i. Stories and metaphors

1. Beware of conceptual traps

2. Stories and metaphors are delivered for purposes of illuminating key points related to the understanding and practice of mindfulness

3. Metaphors and descriptive terms used in guided meditations should be used to connect individuals to an embodied experiential process that aligns with intentions, values, and/or goals

a. For example, how can the term “spaciousness” be experienced within the body-mind, and for what purpose?

e. Case studies

XII. Discussion: What are some ways that mindfulness can be applied to clinical depression (cognitive triad of self, world, future), Anxiety (mental and somatic components), Relationships (thoughts, speech, actions in alignment with values)?

Understanding and applying mindfulness through the orientation of ACT (Acceptance and Commitment Therapy)

I. Acceptance and Commitment Therapy (ACT):

a. What is ACT?

i. “…an empirically based psychological intervention that uses acceptance and mindfulness strategies, together with commitment and behavioral change strategies, to increase psychological flexibility. Psychological flexibility means contacting the present moment fully as a conscious human being, and based on what the situation affords, changing or persisting in behavior in the service of chosen values (Steven Hayes, contextualscience.org).”

II. ACT conceptualization of psychological problems (Steven Hayes, Ph.D.)

a. Most psychological difficulties have to do with the avoidance and manipulation of private events.

b. All psychological avoidance has to do with cognitive fusion and its various effects.

c. Conscious control belongs primarily in the area of overt, purposive behavior.

d. All verbal persons have the “self” needed as an ally, but some have run from that too.

e. Clients are not broken, and in the areas of acceptance and defusion they have the psychological resources they need if they can be harnessed.

f. To take a new direction, we must let go of an old one. If a problem is chronic, the client's solutions are probably part of them.

g. When you see strange loops, inappropriate verbal rules are involved.

h. The value of any action is its workability measured against the client's true values (those he/she would have if it were a free choice). The bottom line issue is living well, not having small sets of “good” feelings.

i. Two things are needed to transform the situation: accept and move.

III. Six Core Processes of Psychological Flexibility (Steven Hayes, Ph.D.)

a. Defusion

b. Acceptance

c. Contact with the present moment

d. Self-as-context

e. Values

f. Committed action

Fusion is about attaching a thought to an experience, identity, or outcome to the degree that the thought dominates

1. Context determines whether it’s appropriate or inappropriate

a. Film/theatre examples

b. Inflexibility of perception and behavior determines dysfunction

2. Mindfulness facilitates cognitive defusion by creating a more objective relationship to thoughts, creating distance from thoughts so that individuals can live with thoughts but not be dominated by them.

a. Creating “space” from thoughts

3. Discussion: How does cognitive fusion function in anxiety and depressive disorders? How does mindfulness facilitate cognitive defusion?

i. Values exercise using Valued Living Questionnaire (VLQ)

1. Discussion

a. Uses

2. Values vs. goals

a. Process vs. outcome

i. Wanting vs. willing

IV. Mindfulness Processes in ACT

a. Facilitate contact with the present

i. This is bidirectional: for the therapist and the client

ii. Build acceptance by defusing language

1. Teach limits of language in experiencing the present moment directly

2. Undermine fusion of self and language

a. Strategy: teach strategies for cognitive defusion

b. Deliteralize language

c. Interventions

i. milk, milk, milk exercise (or use other content)

ii. singing fused thoughts

d. Buying thoughts vs. having thoughts

e. Metaphors and stories

i. passenger on a bus story

ii. thoughts on a train metaphorical exercise

3. Undermine evaluations and reason giving

a. Teach the difference between evaluation vs. description

b. Interventions: reasons vs. causes homework

4. Teach nonjudgmental awareness

a. Promote willingness (vs. wanting) skills

b. Mindful awareness of experience

5. Build acceptance through direct experience

a. Examples

i. Lovingkindness meditation

ii. Self-compassion meditation

iii. Forgiveness exercises

iv. Dyadic exercises in context of couples therapy

V. Undermine attachment to the conceptualized self

1. Show how attachments to self-concepts can be detrimental: mental polarity exercise (“I am perfect” vs. “I am worthless”)

2. Create awareness of self-as-perspective: mindfulness exercises distinguishing consciousness form content of consciousness. Clouds vs. Sky Metaphor. Chessboard Metaphor.

3. Contrast the conceptualized self with the observer self

4. Undermine importance ascribed to feeling, thinking, and acting in inflexible ways that are constrained by self-concept.

a. Faking It Exercise

b. Pick an Identity Exercise

VI. Values Work

1. Values

a. A variety of domains

i. Work

ii. Family

iii. Spirituality

iv. Health

b. Undermine values based upon avoidance, social compliance, or fusion

VII. Commitment and Behavioral Change

VIII. Discussion: Mindfulness for Two (Kelly Wilson, Ph.D.)

How do clinicians…

a. …get ‘fused’ with their thoughts?

i. Favorite theories and explanations

b. …engage in avoidance and control strategies that are contrary to the framework of ACT?

IX. The dynamic between experiential understanding and conceptual understanding

a. This applies to the client as well as the clinician

b. Default to experience, and know the map of the conceptual terrain

c. Remember to work toward psychological flexibility that is grounded in behavioral change, beyond words

X. The FEAR and ACT algorithms (Hayes, Strosahl, and Wilson, 1999)

1. FEAR

a. Fusion with your thoughts

b. Evaluation of experiences

c. Avoidance of your experiences

d. Reason giving for your behavior

2. ACT

a. Accept your reactions and be present

b. Choose a valued direction

c. Take action

Mindfulness, Self-Compassion, and Wellbeing

Two wings of a bird: Wisdom and Compassion

These practices complement mindfulness-based interventions by cultivating acceptance, kindness, security, and safety, allowing the practitioner to engage in the practice of mindfulness in a more stable, balanced, and connected way. Mindfulness practice can trigger dissociation if the practitioner if not sufficiently stable. Acceptance-based practices “associate” the practitioner with emotional and somatic resources.

I. Compassion: The Heart of Mindfulness: Warm attention vs. cool attention

a. “If we practice cultivating this energy of mindfulness every day, we will have enough of it to take care of our pains. Every time pain manifests, we will welcome it. We will really be there to take care of it, and the energy needed to take care of it is without a doubt the energy of mindfulness. This means that the energy of mindfulness is there to embrace the energy of pain." —Thich Nhat Hanh, from "True Love: A Practice for Awakening the Heart"

II. Self-Compassion and Loving-Kindness

a. Acceptance and compassion- based interventions complement mindfulness-based interventions

i. Reinforcement of intentions and values

ii. Another method of increasing ‘positive’ emotions

iii. Have relevance to individuals suffering from self-judgments associated with clinical depression or worries associated with anxiety

iv. Mindfulness and acceptance-based practices work together in a synergistic way

III. Defining Compassion

a. The wish that all living beings be free from suffering. (Dalai Lama)

b. Deep awareness of the suffering of oneself and other living beings, coupled with the wish and effort to alleviate it. (Paul Gilbert, Ph.D.)

IV. Defining Self-Compassion (Kristin Neff, Ph.D./Distinguished from Self-Esteem)

a. Self-Kindness

i. Acceptance, warmth, equanimity

b. Common Humanity

i. Recognition of shared vulnerability and imperfection; interdependence

c. Mindfulness

i. Balancing challenging emotions (neither suppressed nor exaggerated)

ii. Gaining perspective by placing our personal situation into a larger context (shared suffering)

1. Non-judgmental observation; open, receptive attitude

V. Distinguishing Self-Compassion from Self-Esteem

a. The clinical advantages of self-compassion over self-esteem

b. Self-esteem as a developmental precursor to self-compassion

VI. Self-Compassion

a. Research Findings

i. Enhances resilience by moderating reactions to negative events

ii. Greater self-acceptance and optimism

iii. Less negative emotions (they are not rejected; positive emotions are generated by embracing negative emotions)

b. Benefits of Self-Compassion

i. Deactivates the threat system associated with insecure attachment, defensiveness, autonomic arousal

ii. Activates the caregiving system associated with secure attachment, safety, oxytocin-opiate system (Gilbert and Proctor, 2006).

iii. Reduces cortisol, increases HRV - heart rate variability (Rockliff et. al., 2006).

iv. HRV is associated with ability to self-soothe when stressed (Porges, 2007).

VII. Self-Compassion Exercises

a. Heart cradling: hands on heart with gentle acknowledgement of suffering or distress (self and others)

b. Self-Soothing for painful emotions

i. Connect with heart and breath

ii. Connect with bodily location of the tension or pain

c. Mantra repetition (e.g., “soften, allow, and open”)

i. Note: This is more of an ‘aspiration’ than an ‘affirmation’

ii. Aspirations engage the client/patient to be accountable to thoughts, speech, and actions, while affirmations can potentially reinforce magical thinking

d. Breathing compassion in and out (for self and others)

i. Advanced practice of “tonglen”

1. Breathing in pain and breathing out relief

2. Why breathe in pain?

e. Phrases for compassion (C. Germer, Ph.D.)

i. May I be safe

ii. May I be peaceful

iii. May I be kind to myself

iv. May I accept myself just as I am

VIII. Self-Compassion Practice

a. Discussion following the practice

Beyond Symptom Relief: Cultivating Wellbeing

I. What do we mean by “wellbeing”?

a. Suffering reduction?

b. Symptom reduction?

c. Satisfaction with quality of life?

d. Other measures?

e. Mindfulness perspective

i. Skillful thoughts, speech, and actions that cultivate wellbeing of self, others, and community

ii. Attention to present-moment experience

iii. Acceptance

iv. Lovingkindness

v. Compassion

vi. Joy

vii. Equanimity

II. Mindfulness, Wellbeing, and Resilience

a. Clinical matters

i. Preventive factors and skills

1. Acceptance

2. Compassion

3. Cognitive defusion

b. Clinician matters

i. Therapeutic efficacy

ii. Preventing burnout

iii. Mindfulness skills and attitudes

III. Mindfulness in the workplace

a. Research findings

b. Interventions

IV. Wellbeing and chronic illness

a. Mindfulness

b. Compassion

c. Social support

V. Mindfulness and physical health outcomes

VI. MBSR and MBCT

a. Lessons from research

b. Applications to practice

VII. ACT for wellbeing

a. Stress, psychological flexibility, and wellbeing

VIII. Expanding the context of wellbeing

a. Mindfulness as a mind-body practice that can extend to spirituality and religion for some practitioners

b. Mindfulness in groups

c. Mindfulness of lifestyle factors

i. Nutrition and diet

ii. Exercise

iii. Quality of relationships

iv. Social support networks

v. Sleep

vi. Alcohol and other drugs

vii. General self-care

IX. The ‘shadows’ of mindfulness for cultivating wellbeing

a. Dissociation

b. Self-absorption

c. Striving for feeling BETTER rather than FEELING better

X. Intentions, values, and behavior

a. Client-centered behavioral accountability

Mindfulness, Addiction, and Recovery

I. Addiction as Individual Diagnosis and Cultural Metaphor

a. Cultural addictions

i. Dopamine, the brain, and the quest for happiness

b. From the cultural to the personal

i. Addiction to potentially toxic ‘nutriments’

1. Internet

2. Smartphone

3. Television

4. News

5. Unskillful thinking

a. The Cognitive Triad of CBT from a Mindfulness Perspective: Process vs. Content

i. Self

ii. Others

iii. Future

II. Basic Principles of Effective Drug Addiction Treatment According to the NIDA’s Research-Based Guidelines

a. Addiction is a complex but treatable disease that affects brain function and behavior.

b. No single treatment is appropriate for everyone.

c. Treatment needs to be readily available.

d. Effective treatment attends to multiple needs of the individual, not just his or her drug abuse.

e. Remaining in treatment for an adequate period of time is critical.

f. Behavioral therapies—including individual, family, or group counseling—are the most common forms of drug abuse treatment.

g. Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies.

h. An individual's treatment and services plan must be assessed continually and modified as necessary to ensure that it meets his or her changing needs.

i. Many drug-addicted individuals also have other mental disorders.

j. Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug abuse.

k. Treatment does not need to be voluntary to be effective.

l. Drug use during treatment must be monitored continuously, as lapses during treatment do occur.

m. Treatment programs should test patients for the presence of HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious diseases as well as provide targeted risk-reduction counseling, linking patients to treatment if necessary.

III. Understanding the problem of addiction beyond the Disease and Moral Models

a. A complex Biopsychosocial Problem involving multiple causal factors

IV. Overview of Mindfulness-Based Interventions for Addiction

a. Forms of Mindfulness-Based Interventions

b. Research Findings

c. Hypothetical neurological mechanisms of mindfulness-based interventions

V. Mindfulness skills, bio-behavioral mechanisms, and clinical outcomes (adapted from Garland and Howard, 2018)

a. Skills

i. Mindful Breathing

ii. Body Scan

iii. Mindfulness of Craving

1. Curiosity as an important attitudinal orientation (Brewer’s work)

iv. Informal Mindfulness

b. Biological mechanisms

i. Amplifying prefrontal activation

ii. Increasing frontostriatal connectivity

iii. Decreasing limbic reactivity

iv. Improving regulation

c. Behavioral mechanisms

i. Restructuring reward processing

ii. Boosting executive function

iii. Strengthening dispositional mindfulness

iv. Reducing stress reactivity

v. Decreasing drug cue-reactivity

vi. Minimizing thought suppression

d. Clinical outcomes

i. Decreased craving

ii. Reduced substance use

iii. Decreased distress

iv. Enhanced well-being

v. Meaningful recovery

VI. Other skills and applications of mindfulness

a. Mindfulness in relationship

i. Work

1. Relationships with co-workers

2. Relationships with supervisors

3. Relationships with subordinates

ii. Home

1. Parenting

2. Relationship with partner

b. Self-care

i. Diet

ii. Exercise

iii. Habits of wellbeing

iv. Sleep

c. Recovery in community

i. Mindful speech

ii. Awareness of relationship strengths and vulnerabilities

d. Relapse prevention

i. Goal of Mindfulness-Based Relapse Prevention

1. “The goal of MBRP is to develop awareness and acceptance of thoughts, feelings, and sensations through practicing mindfulness, to observe both pleasant and unpleasant experience, and to accept whatever is present without judgment. These practices are combined with traditional relapse prevention techniques for developing effective coping skills, enhancing self-efficacy, and learning to recognize common antecedents of substance use and relapse (e.g., outcome expectancies, the abstinence violation effect, drinking motives, social norms, and risk perception) (Marlatt et al., 2008).”

ii. “Urge surfing”

iii. Awareness of emotional and cognitive responses to triggers

iv. Awareness of high-risk situations

1. Identifying high-risk situations is a central element of the treatment

v. Acceptance

vi. Assessment of lifestyle factors

vii. Therapeutic role

1. The quality of the therapeutic alliance is a significant factor in treatment efficacy

2. Importance of therapist’s personal mindfulness practice

3. Embodiment of acceptance, non-judgment, curiosity, and compassion

4. Humanizing, not stigmatizing

5. A collaborative approach

6. Unconditional positive regard

7. Facilitating of self-efficacy

a. Small steps toward the goal are important

VII. Self-compassion training

VIII. ACT skills for recovery

a. Present moment experience

b. Acceptance

c. Cognitive defusion

d. Self as context

i. Distinguishing the ‘experiencer’ from the ‘experience’

1. Examples

a. Craving

b. Problematic self-narratives

e. Values work

f. Committed action

Applications of Mindfulness in Clinical Practice: Depression and Anxiety

I. Treating people or diagnoses?

a. Lessons from ACT: Targeting suffering or symptoms?

i. A transdiagnostic approach involving similar processes and skills, regardless of diagnosis

b. Cultivating skills vs. reducing symptoms

II. Research findings

a. MBCT is effective in reducing relapse in individuals with Major Depressive Disorder

b. MBSR shown to be effective in reducing severity of anxiety and depression

III. Mindfulness and acceptance-based interventions

a. Third-Wave of Cognitive-Behavioral Therapies

i. DBT

ii. ACT

iii. MBSR

iv. MBCT

b. Moving away from treating diagnoses and moving toward therapeutic processes and skills

IV. Mindfulness and CBT

a. Both mindfulness and CBT aim to reduce suffering and combine cognitive and behavioral exercises

b. Both desensitize conditioned fear responses

i. Mindfulness-based interventions (MBIs) achieve this through the cultivation of attention and observation

ii. CBT directly intervenes with exposure-based practices

c. Perspective on internal experiences (thoughts, feelings, sensations)

i. MBIs promote observation and cognitive defusion

ii. CBT involves directly challenging cognitive distortions

d. Both treatments incorporate relaxation

e. Differences in MBIs and CBT

i. Accepting vs. changing maladaptive cognitions

1. Cognitive defusion vs. cognitive restructuring

ii. CBT can be seen as more goal-oriented than MBIs

V. Key issues in treating individuals suffering from depression

a. Level of functioning

b. Suicidality

c. Support system and relationship dynamics

d. Medical issues

i. Chronic illness

ii. Medications

e. Experiential avoidance and control

VI. Mindfulness-based interventions in treating individuals suffering from depression

a. Lessons from ACT

i. Assess psychological flexibility

ii. Identify core values

iii. Assess ability to take effective action in alignment with core values

b. Mindfulness meditation

i. Non-attachment to cognitions

1. Cognitive defusion

ii. Meditating “with depression” vs. meditating “in order to” eliminate depression

c. Mountain meditation

i. Cultivating equanimity

d. Self-Compassion practice

i. Kindness

1. Unconditional kindness through thoughts, speech, and actions directed toward self and others

ii. Common humanity to foster sense of connection and reduce alienation

iii. Mindfulness to moderate emotional reactivity

e. Lovingkindness practice

i. Cultivating the aspiration for caring

f. Joy meditation

i. Appreciative joy

ii. Resonant joy

g. Body Scan

h. Mindfulness-based relaxation training

i. Mindful Movement

i. Yoga

ii. Qigong

iii. Tai Chi

iv. Walking

VII. Key issues in treating individuals suffering from anxiety

a. Level of functioning

b. Support system and relationship dynamics

c. Medical issues

i. Chronic illness

ii. Medications

d. Experiential avoidance and control

e. ‘Bad habits’ as anxiety in disguise

i. Attention

ii. Curiosity

VIII. Mindfulness-based interventions in treating individuals suffering from anxiety

a. Lessons from ACT

i. Assess psychological flexibility

ii. Identify core values

iii. Assess ability to take effective action in alignment with core values

b. Mindfulness meditation

i. Non-attachment to cognitions

1. Cognitive defusion

ii. Meditating “with anxiety” vs. meditating “in order to” eliminate anxiety

1. Being with the sensations of somatic symptoms of anxiety is valued over reducing or eliminating the symptoms

a. The paradox of symptom reduction when striving for an outcome is relinquished

i. Process-Progress-Paradox

c. Mountain meditation

i. Cultivating equanimity

d. Joy meditation

i. Appreciative joy

ii. Resonant joy

e. Body Scan

f. Mindfulness-based relaxation training

g. Mindful Movement

i. Yoga

ii. Qigong

iii. Tai Chi

iv. Walking

IX. Creative interventions that can be applied to depression and anxiety

a. Postures for embodying openness while reciting troubling thoughts aloud or silently

b. Singing the distorted or troubling thought

c. Moving with the cognition

d. Using creative interventions will of course be dependent upon timing, client willingness, ability, severity of psychopathology, and appropriateness within the context of the therapeutic relationship

X. The key to amplifying treatment efficacy outside of the clinician’s office

a. Practice!

i. Working with motivation

1. Small daily steps are more effective than one large step

2. Explicit practice goals

3. Discuss what might interfere with reaching practice goals

4. Homework tasks

a. Be clear

b. Be specific

c. Ensure that the client understands the task and is willing

i. If possible, practice the behavioral task or skill within the session before assigning it

5. Follow-up on homework during the next session

a. Homework may have been:

i. Fully completed

ii. Partially completed

iii. Not completed or approached

b. Discuss what helped or hindered action in alignment with practice goals and accompanying values

Applications of Mindfulness in Clinical Practice: Relationship Dysfunction

I. Mindfulness in Relationships: An Overview

a. Mindfulness-based behavioral orientations and skills that support healthy personal and professional relationships

i. Acceptance

ii. Lovingkindness

iii. Compassion

iv. Joy

v. Equanimity

vi. Letting go

vii. Mindful listening

viii. Mindful speech

1. Is it true, necessary, well-timed, and kind?

2. Do your words create connection or division?

ix. Mindful relaxation and self-care

x. Awareness of interbeing

xi. Mindfulness of individual and shared woundedness

xii. Awareness of the conditioned nature of beliefs, perceptions, and actions

xiii. Awareness of shared values

xiv. Cultivation of actions based upon shared values

II. Perspective from Mindfulness Practice

a. Five A’s of Mindful Relationships (From “How to be an adult in relationships” by David Richo)

i. Attention

ii. Acceptance

iii. Appreciation

iv. Affection

v. Allowing

III. Perspective from Humanistic Psychology

a. Four elements of the art of loving that must be practiced (Erich Fromm):

i. Care

ii. Responsibility

iii. Respect

iv. Knowledge

IV. Perspective from Buddhist Psychology

a. Four Qualities of True Love (Thich Nhat Hanh)

i. Love (or lovingkindness)

ii. Compassion

iii. Joy

iv. Equanimity

V. A Research-Based Perspective

a. Seven Principles for Making Relationships Work (Gottman)

i. Enhance your ‘Love Map’: In Knowledge there is strength

1. get to know your partner’s world, including friends, competitors, stresses, important events, worries, hopes and dreams

ii. Nurture fondness and admiration for each other

1. get to know what you like and appreciate about one another and express that appreciation on a regular basis. This is the antidote to contempt, which is extremely destructive to an intimate relationship

iii. Turn toward each other instead of away

1. Be mindful of partner’s emotional needs. Mindlessness is usually not maliciousness, but can diminish intimacy in a relationship.

2. Bids for connection

a. Turning against

b. Turning away

c. Turning toward

3. Eye contact, body posture, expressing empathy, compassion, and solidarity, expressing affection, validating emotions

iv. Let your partner influence you

1. the wives of men who accept their influence are much less likely to be harsh with their husbands when discussing a difficult marital topic.

v. Solve your solvable problems

1. Soften your startup

a. Complain but don’t blame

b. Make statements that start with “I” instead of “You”.

c. Describe what is happening rather than judging, blaming, or labeling

d. Be clear

e. Be polite and respectful

f. Be appreciative

g. Don’t store things up

h. Learn to make and receive repair attempts

i. Soothe yourself and each other (take ‘time out’ if needed)

j. Compromise

k. Accept each other’s faults

vi. Overcome gridlock by working towards understanding rather than getting your way.

1. get to know your partner’s needs and dreams

vii. Create a shared meaning system

1. What are your intentions?

2. What are your values?

3. What are your goals?

4. The importance of rituals for connection.

a. rituals amplify and focus the meaning in a relationship

b. remember that ‘meditation’ can be a ritual for connection

i. individual

ii. dyadic

VI. Values vs. goals

a. Values are different than goals. They assist us in looking at self, other people, and the world through the lens of what’s valued.

b. A value is like a directional compass that orients us to a path, while a goal is like a specific destination.

c. Examples in relationship with regard to three C’s of Communication, Conflict Management, and Connection

VII. Mindfulness, values, restraint, and cultivation

a. Thoughts

i. Cognitive defusion

ii. Cultivation

1. Lovingkindness and compassion practices

b. Emotions

i. RAIN

1. Recognize

2. Allow

3. Investigate

4. Non-identify or nurture with acceptance and compassion

c. Speech

i. Restraint

1. Restraint is a values-based behavior, not a forced tolerance or internalization of negative affect

ii. Cultivation

d. Actions

i. Restraint

ii. Cultivation

VIII. An ACT Perspective (Harris)

a. Conceptualization of relationship problems

i. Two questions

1. What do they want to create?

2. What stands in their way?

a. What are they fused with?

b. What are they avoiding?

c. What ineffective actions are they taking?

b. History taking

i. Assessing shared values

ii. What kind of partner do you want to be?

iii. What kind of relationship do you want to create?

c. Common Core Values

i. Connection

ii. Caring

iii. Contribution

d. Moving from values to goals

i. What’s a small step you can take toward your goal?

ii. If your partner takes that step, what difference would it make to you and how will you let them know that?

e. If desired changes are not made

i. What was that like for you?

ii. What happened to your relationship as a resut?

iii. What got in the way?

f. Barriers to change: FEAR (‘official’ ACT version; this can work more effectively with individuals in many instances)

i. Fusion

ii. Evaluation

iii. Avoidance

iv. Reason-giving

g. Barriers to change: FEAR (‘alternative’ version)

i. Fusion

ii. Excessive expectations

iii. Avoidance

iv. Remoteness from values

h. The antidote to FEAR is DARE

i. Defusion

ii. Acceptance

iii. Realistic expectations

iv. Embrace values

i. Key issues

i. Four approaches to the problem

1. Leave

2. Stay and change what can be changed and live by your values

3. Stay and accept what can’t be changed and live by your values

4. Stay and give up and increase your suffering through self-defeating behaviors

ii. Behavioral change issue

1. What’s in your control?

2. What’s not in your control?

iii. Communication basics

1. Ask clearly for what you want, (and explain why)

2. Express clearly what you don’t want, (and why)

3. As you do this, be the partner you want to be!

4. Boundaries and consequences

iv. When you’re upset or triggered:

1. Breathe out

2. I notice I’m feeling x

3. I’m having the thought that ..

4. Get present; ground yourself

5. If necessary, leave the situation

a. If you do leave, practice mindfulness and acceptance (practice letting go of unhelpful stories)

v. Once grounded, ask yourself

1. What sort of partner do I want to be? What are my values here?

2. If I could be that ideal partner, I would respond by doing …

3. Then take action, guided by those values

4. Visualize/write/rehearse those responses

vi. In other words: ACT

1. Accept your thoughts and feelings

2. Connect with your values

3. Take effective action

4. Or more simply:

a. Be present and do what matters!

vii. Dealing with conflict in session

1. Stop arguments in session

2. Do mindfulness then and there

3. What’s your body doing? Breathe into it.

4. What’s your mind saying? Name it.

5. What judgments does your mind make about him/her?

6. What happens if you buy those judgments?

7. I’m making the judgment that…

8. Being right versus being loving

a. The gridlocked trap of “I’m right; you’re wrong.”

9. Discuss inevitability of conflict

a. A sign of connection!

10. Increase awareness of triggers

11. Increase acceptance

12. Discuss common arguments or annoyances

13. Name your stories

14. ‘But’ vs ‘And’ thinking

15. Anger management or self-regulation training if necessary

16. Repair attempts (Gottman)

a. What’s the smallest step you could take that might repair some of the damage?

b. Acknowledge and accept repair attempts

viii. Reframing problems

1. How can I grow from this?

2. What can I learn from this?

3. What ACT skills will this enable me to improve?

4. Imagine your partner is a teacher: what is the lesson?

ix. Facilitating behavioral change

1. Willingness to change, versus wanting to change

2. Facilitate willingness through values

3. Distinguish values-driven change from: resentful change/ guilt-induced change/ trying to ‘keep her happy’/ trying to ‘put up with him’

4. Identify barriers: FEAR

5. Discuss ‘relapse’

a. When your partner slips up, how will you respond?

x. Love

1. Distinguish the action of love from the feeling of love

2. If you had a magic wand, how would you be loved?

xi. Intimacy (In to ‘me’/ ‘see’)

1. Be present

2. Share valued activities

3. Practice connection

4. Eye contact

xii. Compassion for self and partner

1. Kindness

2. Commonality of human experiences

3. Mindfulness

4. Being there as a safe partner for soothing and alleviating suffering

xiii. Trust

1. Distinguish the action of trust from the ‘feeling’ of trust (not really a feeling; more a ‘sense’ – strong cognitive component)

2. No control over ‘feelings’ of trust – only over the actions.

3. Balance values around trust with values around self-protection

IX. Mindfulness-based perspectives on healing relationships

a. Intention

i. An aspiration (vs. affirmation) toward what you want to cultivate

ii. An orientational direction

1. Supported by conscious choices and actions moving you in a valued direction

2. What do you want to create?

3. What values do you want to be expressed and integrated into your relationship?

a. Thoughts

b. Speech

c. Actions

d. Practice, practice, practice

iii. Garden metaphor

1. What do you want to grow or cultivate?

a. What nutrients are needed?

i. If weeds were your problems and challenges, how can you grow more flowers instead of focusing on the weeds?

b. Compassion

i. Understanding

ii. Being there in times of pain

iii. Relating from ‘the heart’

c. Wisdom

i. Emotional understanding

ii. Knowledge

1. What makes relationships work

2. Knowledge of self

3. Knowledge of partner

a. Includes knowledge of wounds, vulnerabilities, ‘shadow’ aspects, and hopes and dreams

4. Awareness of shadow aspects

a. Keys to becoming aware of shadow/unconscious conflicts in relationship

i. Emotional intensity

ii. Judgments

iii. Criticism

iv. Blame

v. Labeling

vi. Black and white thinking

vii. Dreams about your partner

b. Advanced perspectives

i. See the other as ‘shadow ally’, helping you to become more conscious of your wholeness

ii. Recognize the ‘golden shadow’

1. The admirable qualities that you deny or avoid in you and your partner

a. Increase awareness of possibilities by looking for the opposite of what disturbs you in yourself and your partner

X. The Three poisons of Buddhist Psychology: A Map of Suffering and the Antidote to Suffering

a. Attachment (Greed)

i. Antidote = Generosity or letting go

b. Aggression (Anger/Hatred/Aversion)

i. Antidote = Loving-kindness or simply Love

c. Delusion (Ignorance)

i. Antidote = Wisdom

1. Understanding the nature of the mind and reality (e.g., ‘impermanence’)

2. Understanding that each of the so-called ‘mental poisons’ are the consequence of conditioning. Mindfulness practice help to make us less conditioned and unconsciously reactive.

a. Understanding conditioning can support a non-blaming, growth-oriented perspective that cultivates acceptance and compassion

XI. Mindfulness-based practices and interventions

a. Dyadic open-eyed meditation

i. Looking into the eyes of the partner without words or touching

ii. Looking through the eyes of acceptance and compassion

iii. Being seen by the eyes of acceptance and compassion

b. Dyadic close-eyed meditation

i. Upon conclusion, telling your partner what you appreciate about them

ii. Telling your partner what you would like them to know or understand about you

c. Dyadic Loving-Kindness and Compassion-Based Meditations

d. Mindful movement

i. Mindful movement can integrate an attitude of playfulness within relationships

1. Slow movements

2. Attention to self and other

ii. Playful ‘flowing hands’ exercise

e. Mindfully breathing together

i. Synchronizing breathing

f. Common humanity meditation facilitated by clinician

i. From birth, through developmental milestones, and to death

ii. This is somewhat of an advanced practiced, that must be used with care.

Applications of Mindfulness in Clinical Practice: Treating insomnia and other dysregulations of sleep

I. Brief overview of sleep

a. Scope of problem

b. Essential points to consider

i. Medical and psychiatric status

ii. Morning light and evening darkness to adjust circadian rhythms

iii. Sleep environment

iv. Exercise and stress management

v. Consumption of ‘nutriments’: food, alcohol, caffeine, and electronic stimulation

II. The 3-P Model of Self-Assessment

a. Predisposing Factors: Appreciating our history, without being identified with it

i. History of stress-related poor sleep

ii. Is this a chronic problem or related to situational stress?

iii. Appreciate the stress that we have habituated to, not necessarily in a skillful or helpful way.

iv. Disruption in rhythms and routines

b. Precipitating Factors: Mindfully observing what’s happening in your current life: Medical, environmental, and psychosocial stressors that activate a pattern of poor sleep.

i. Medications

ii. Caffeine, alcohol, and other drug consumption

iii. Relationship stress

iv. Depression and anxiety

v. Environmental: noise and light

c. Perpetuating Factors: Observing the habits that may reinforce insomnia

i. The attempted ‘solution’ can sometimes compound the problem

ii. When an adaptation compounds or reinforces the problem

iii. Behaviors and other factors that perpetuate the pattern

1. Example: drinking to relax before bedtime

2. Example: watching TV or surfing the internet in the bedroom to wind down: Blue light exposure!

3. Any attempt to control that creates more arousal

III. Mindfulness Beyond Meditation

a. Brief definition of mindfulness (contemporary and ancient perspectives)

b. Mindfulness meditation helps us to slow down and carefully attend to how we can make adjustments in our life to support sleep.

i. Mindfulness meditation is a practice of training the mind and body to be present, open, accepting, and compassionate without judgment.

1. It’s NOT about making your mind blank; it’s more about tending to the distractions that reduce your focus

2. It’s NOT about positive thinking; it’s about awareness of thinking and other experiences, without attaching yourself or reacting to them

c. Awareness of habit patterns, including negative thoughts about sleep

d. Calming through mindfulness-based relaxation that balances neurochemistry, reducing adrenaline and cortisol. “Turning down the noise” to support in a more relaxed nervous system, leading to “self-regulation” (the process of systems within the body become stable and adaptable). It can be as simple as slow, deep breathing.

i. Decreases anticipatory anxiety that can lead to chronic insomnia

e. Awareness of bodily signals such as yawning and spontaneous eye closure at night.

f. The possibility of pausing, stopping, reflecting, and regulating your thoughts and actions

g. Thoughts, Perceptions, and Beliefs about Sleep

i. How do you consider sleep?

ii. Do you regard it as important as diet and exercise?

IV. Mindfulness for Sleep

a. Mindfulness vs. Medications: Meditation or Medication?

i. Research by Gross et. al. (2011) demonstrated that an eight-week MBSR training + 10-minute sleep education and all-day retreat was as effective as the FDA-approved sedative hypnotic Lunesta in the treatment of chronic insomnia.

b. Jason Ong and associates propose a “Metacognitive awareness” model that integrates mindfulness to decrease the arousal associated with not being able to easily adopt an objective perspective about insomnia. This makes us ‘blind’ to maladaptive cognitive, emotional, and behavioral reactions to sleep disturbance. His work describes four ways that problem sleep can result in “secondary arousal” and four adaptive ways to reduce this secondar arousal:

i. Attention and emotional bias toward sleep-seeking or sleep-aversive thoughts and behaviors > Shift to Balance > Allow the state of sleepiness to guide sleep-related behavior (“Improving sleep with mindfulness and acceptance: A metacognitive model ...”)

ii. Rigidity in sleep-related behaviors and beliefs > Shift to Flexibility > Adjusting intentionally to changing conditions > Consider what will support your sleep rather than worry about what’s disrupting your sleep

iii. Attachment to sleep-related needs and expectations > Shift to Equanimity > Calmness stemming from non- striving and patience about sleep > Gratitude and Breathing practices can be helpful

iv. Absorption in solving the sleep problem (goal orientation) > Commitment to values > Pursuit of valued living in the context of the range of thoughts and emotions > Mindfulness attitudes and values of openness, letting go, acceptance, compassion

V. Cognitive approaches to sleep problems

a. Cognitive-Behavioral Therapy for Insomnia (CBT-I)

i. CBT-I focuses upon:

1. Conditioned arousal (e.g., watching TV in bed)

2. Identifying and eliminating ineffective habits intended to improve sleep

3. Reducing sleep-related worry and hyper-arousal

b. Strategies

i. Sleep restriction: restricting amount of time in bed (e.g., no naps), which increases the drive for sleep

c. Stimulus control

i. instructions for using the bed and bedroom as environmental stimuli to induce sleep (Pavlov’s Bed!)—don’t go to bed until sleepy; getting out of bed if awake for a specified duration of time (e.g., 15 minutes). Bed is used for sleep and sex only.

ii. Remove electronic stimulation

1. No smartphones, computers, or TVs in the bedroom!

d. Reducing worry

i. NSTs vs. PSTs

e. Reducing sleep interfering arousal: eye masks and ear plugs; blackout shades; decluttering; removing electronic stimulation.

f. Monitoring foods and substances

g. Working with biological rhythms

VI. ACT for Insomnia: “Acceptance and Commitment Therapy (ACT) offers a unique and gentle non-drug based approach to overcoming chronic insomnia. It seeks to increase people’s willingness to experience the conditioned physiological and psychological discomfort commonly associated with not sleeping. Such acceptance paradoxically acts to lessen the brain’s level of nocturnal arousal, thus encouraging a state of rest and sleepiness, rather than struggle and wakefulness (Acceptance and Commitment Therapy for Insomnia {ACT-I} by Dr. Guy Meadowns. Retrieved from https://contextualscience.org/acceptance_and_commitment_therapy_for_insomnia_act).”

a. Acceptance and Commitment Therapy (ACT)

i. Premise: control and avoidance create suffering

ii. The use of acceptance and mindfulness

1. Acceptance is an antidote to avoidance and control

iii. Through reducing arousal, Acceptance is also an antidote to the suffering that’s associated with insomnia

1. Primary arousal = awake when intending to sleep

2. Secondary arousal = anxiety and worry over being awake

b. Mindfulness has many functions in the context of healing insomnia

i. Awareness of habits that interfere with sleep

ii. Awareness of actions that support sleep

iii. Identifying sleep-interfering cognitions (perceptions, thoughts, beliefs)

iv. Cognitive defusion reduces the power of thoughts, judgments, and stories

1. Creates space from your thoughts by seeing your thoughts as ‘just thoughts’ like clouds passing through the sky.

a. Disidentification

b. Nonreactivity

c. Reducing attempts at controlling the sleep process

i. The paradox of trying to relax in bed or trying to sleep

ii. Paradoxical intention

VII. Cognitive Defusion Exercise > Waiting for the Train

VIII. Differences between CBT-I and ACT-I in Sleep-Related Activities (Meadows, G.)

a. Allow normal bedroom activities

i. CBT-I: NO - Use the bed for sleep and sex only

ii. ACT-I: YES - Allow calm non sleep activities such as reading in bed

b. Go to bed when either tired or sleepy

i. CBT-I: NO - Only when sleepy

ii. ACT-I: YES - Both states allowed

c. Stay in bed, if awake at night

i. CBT-I: NO - If not asleep within 15mins, go to a spare room/read

ii. ACT-I: YES - Focus on resting and welcoming discomfort

b. Allow daytime naps

i. CBT-I: NO - Avoid all daytime napping

ii. ACT-I: YES - Allow a short (<20mins) daytime naps

IX. Hindrances to mindfulness and self-compassion for sleep

a. Attachment to (and identification with) our story, our suffering, our judgments

i. Antidote: Observation, letting go, and connecting with the body, breath, and heart

b. Attachment to the desired outcome of sleep: Trying to sleep

i. Antidotes

1. relaxing into the present moment

2. letting go

3. paradoxical intention

c. Habitual Routines and Compulsive Activity (Doing)

i. Antidote: Take time for being

1. Nature

2. Relaxation

3. Meditation

d. The Need to Know and Understand

i. Faith vs. Hope

ii. The Power of Belief

e. Avoidance of Discomfort

i. Attempts to control our inner experience

1. Let go and let be

2. Step outside the mind stream (narrative) and connect with the sensory stream of the body

f. Aversion

i. Apply lovingkindness

1. Reflect on basic goodness/good deeds

ii. Shift focus

1. Drop the story, and expand focus to sensations

g. Doubt

i. Inquiry

ii. Education

iii. Experiential exploration

X. 5 Skills for Mind-Body Regulation to support Deep Sleep (The 5 Rs)

a. GUIDE through each of these: EXPERIENTIAL is the teaching method

b. Rooting

c. Relaxation

d. Respiration

i. Breath research (5.5 breaths per minute…5 to 6 seconds inhale/5 to 6 seconds exhale). Deep breathing exercise. Vagal nerve activation

1. HRV and vagal tone

ii. Physiological sigh

1. Double-breath in, single long breath out through the mouth (Huberman)

a. For stress and anxiety relief, general relaxation, and sleep

e. Rhythm

i. Panoramic Vision

ii. Integrated with rhythm

f. Remembering

i. Mindfulness

ii. Returning to the body and breath in the present moment

Supplementary Notes for Mindfulness Skills in Clinical Practice

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