The practice of mindfulness, which was little known in established therapy and healthcare circles until a few years ago, is now generating much interest. Mindfulness has its roots in ancient meditation teachings and, being about the cultivation of a non-judgmental, non-striving kind of awareness, can seem puzzling to people in a western culture underpinned by scientific materialism and the protestant work ethic, and favouring goal-setting and rational problem-solving behaviour¹. However, the interface between conventional and mindfulness-based approaches is rich ground for exploration, creativity and cross-fertilisation, and here both traditions contribute their particular qualities and strengths. Mindfulness-based approaches promote qualities such as open-mindedness, patience and trust, which can facilitate the deep listening and empathy needed to bring about understanding. Western science bridges two apparently contrasting approaches through exciting new discoveries about neuroplasticity, which are confirming beneficial changes in the neural circuitry of meditators’ brains². There is also a growing body of social scientific research establishing that mindfulness practice is associated with improved mental and physical health³.

Mindfulness-based approaches have recently achieved a higher profile in the UK through the work of a group of psychologists – Zindel Segal, John Teasdale and Mark Williams – who went to the USA to find out about the mindfulness-based stress reduction (MBSR) programme developed by Dr Jon Kabat-Zinn in 1979. As an experienced practitioner of mindfulness meditation, Kabat-Zinn realised the benefits that this approach could potentially bring to hospital patients suffering from chronic illnesses and stress. He developed a form and language for teaching mindfulness that westerners could easily assimilate⁴. Segal, Teasdale and Williams evolved their own approach, called mindfulness-based cognitive therapy (MBCT), which is based on Kabat-Zinn’s eight-week course model but incorporates some specifically cognitive behaviour therapy (CBT) elements. This group published research that has been validated in National Institute for Health and Clinical Excellence (NICE) guidelines⁵, and has helped mindfulness-based approaches to become recognised within the NHS as an effective response to recurring depression⁶.

What is mindfulness?
Mindfulness is a specific way of intentionally paying attention. It involves observing the mind and body experience from moment to moment without judging, labelling or trying to fix or change anything. Habitual reactions are noticed as they arise in the present and the student/client is encouraged to respond with curiosity and equanimity to whatever comes up. Jon Kabat-Zinn has described the ‘attitudinal foundations’ of a mindfulness-based approach as having the qualities of non-judging, patience, ‘beginner’s mind’, trust, non-striving, acceptance and letting go⁴.

Mindfulness by its nature encompasses all experience and is not confined to any formal practice. It can be practised in daily life in any situation, posture, activity or emotional state. The value of practice is to gradually accustom the mind to being fully awake and aware of whatever is going on internally and externally in each moment, for as much of the time as possible, rather than continually drifting off into thoughts, planning or daydreams about past or future.

Hows and whys of mindfulness
How is mindfulness practised and why is it relevant to current therapeutic practice and self-help? Mindfulness practice is therapeutic because it cultivates a way of being in which habitual patterns of response, which are often associated with incompletely processed past experiences, can come into awareness and be acknowledged non-reactively in the present. By meeting such experiences mindfully, the conditioned patterns naturally begin to have a less powerful hold and, over time, can disappear⁷. Mindfulness also facilitates a way of being in the present in which new tensions and stresses are less likely to be created and stored. The net effect of allowing old complexes to dissolve and creating fewer new ones is a gradual transition towards greater wholeness and wellbeing.

Perhaps most importantly, mindfulness helps us to realise that things can change and come into balance when we do not add an extra layer of agitation to a situation by thinking about how to change it. From a mindfulness perspective, discursive logical thinking is not always the most helpful way to resolve difficulties, and in fact often makes things worse. This is the core paradox of mindfulness: that doing nothing except remaining aware can bring about profound changes⁴. The analogy of a glass of cloudy apple juice has been used to illustrate this – if we keep stirring the juice it will stay cloudy but if we just let it be we will see the sediment settle and the juice become clear naturally in its own time. In the same way, the mind will tend to become clear and settled by simply observing it mindfully⁸. The examples of Jenny and Adrian (below) demonstrate how practising simply stepping back and letting go of habitual reactions and accessing inner ‘breathing space’ over time can be deeply therapeutic.

The meaning of practice
The word ‘practice’ in the traditional healthcare sense implies a practitioner’s role in treating a patient (who is a passive recipient) and administering remedies. In the humanistic therapeutic sense, the meaning of ‘practice’ shifts to convey a relational process between client and therapist, in which the client is an active partner. In terms of mindfulness-based therapy, ‘practice’ shifts its meaning again to refer to the formal and informal meditation practice that both therapist and student/client undertake, so creating a context of ‘co-meditation’⁹. A mindfulness-based therapist will usually regard their mindfulness practice as the foundation of their work and life, and will encourage clients to develop their own mindfulness practice, formal and/or informal, which can be integrated into their lives. As such, mindfulness is fundamentally empowering, and is the ultimate self-help approach.

Delivering mindfulness-based approaches
In terms of therapy and health practice, mindfulness-based approaches are generally delivered in two ways: in the form of eight-week mindfulness groups, or as an integral part of the psychotherapeutic approach of one-to-one therapists. Other mindfulness-based approaches include dialectical behaviour therapy (DBT)¹⁰ and acceptance and commitment therapy (ACT)¹¹.

Mindfulness groups
Eight-week groups are usually based on the MBSR or MBCT models. Participants are guided through an experiential programme in which they learn and explore mindfulness practices. Mindfulness groups are being offered in many contexts, including hospitals, hospices, mental health centres, pain clinics, drug and alcohol centres, speech therapy departments, eating disorder clinics, GP surgeries, schools, prisons and Buddhist centres. There are a growing number of groups for the general public, and also distance learning courses. Mindfulness-based approaches can be used in working with most client groups as the nature and context of any presenting issue is invariably less relevant than the willingness and capacity of individuals to practise mindfulness in their daily lives.

In MBCT groups there is a specific focus on recognising and dealing with ‘rumination’, which is seen as a potential precursor to depression. A single negative thought can often lead to a rapid chain reaction of increasingly catastrophising thoughts and feelings, culminating in a sense of paralysing fear and/or hopelessness. A mindfulness-based approach encourages people to become increasingly aware of their thoughts as they arise moment by moment, and this makes it possible to catch the initiating negative thought/s and to see them as ‘just thoughts’, not facts⁶. When the potential cascade of negative thoughts is interrupted, a mental space is accessed in which the person can re-centre themselves in the present.

Mindfulness groups are not therapy groups, and applicants are informed that they will be learning a new way of relating to difficulties rather than exploring the content of their difficulties in the group. Mindfulness by its nature can bring difficult feelings to the surface. It may not be possible for someone whose mind state is chronically chaotic or overwhelmed to bring themselves back to being present with their feelings, and, in such cases, a primarily containing and supportive therapy approach may be more helpful.

Home practice is seen as a very important part of the eight-week group process, and prospective participants are asked if they can commit to a daily routine of mindfulness practice, since an intellectual understanding of mindfulness alone is considered insufficient to bring about significant changes⁴.

Mindfulness group teachers come from a wide variety of professional backgrounds and include psychologists, psychiatrists, teachers, psychotherapists, GPs, speech therapists, musicians, drama and yoga teachers and Buddhist meditators. There is currently no accreditation process for becoming a mindfulness group teacher, though most teachers will have undergone trainings in MBSR or MBCT, and they will usually be fully qualified professionals in their own field. Master’s courses in MBCT are run by the University of Wales Bangor, Oxford University and Exeter University.

Example: A mindfulness group commissioned by a GP surgery
A colleague and I are running a series of eight-week mindfulness groups of up to 16 patients for a GP surgery within the Herefordshire PCT. A GP in the practice has a strong interest in mindfulness-based approaches and was keen to find out whether patients with chronic ailments would be helped to feel better, have fewer symptoms and/or manage their conditions better themselves as a result of being introduced to a mindfulness-based self-help approach. PCT funding was procured, initially for a series of three courses.

GPs have referred patients who have a wide range of physical and mental health problems and attend the surgery frequently. During the course, participants are introduced to practices that are designed to cultivate the ability to bring mindful attention to different aspects of their experience, including the breath, body sensations, emotions, moods, thoughts, movement and daily routine activities. As the emphasis is on experiencing rather than talking about mindfulness, the sessions always begin with a 30-minute practice followed by an enquiry, a space in which people can share and reflect on their experience. Time is always taken to talk about how the daily home practice is going and to explore any difficulties. CBT exercises to support a mindful relationship to thoughts, and poems and readings that communicate the qualities of mindfulness, are interspersed with the practices. Patient outcomes are being evaluated via three questionnaires given before and after the courses.

The questionnaires used are the EQ-5D health outcome measure¹², (which evaluates levels of physical pain and discomfort, anxiety and depression, mobility, self-care and activity), FANLTC¹³ (functional assessment of non-life-threatening conditions, which measures wellbeing in terms of physical, emotional, functional and social and family factors), and the Freiburg Mindfulness Inventory¹⁴ (which specifically looks at the degree to which a person is mindful in their daily life). Feedback from the first group to complete a course has been very positive, with the majority of participants reporting significant benefits in their daily lives, eg in managing chronic pain, dealing better with anxiety and stressful situations, eating more healthily and less, and feeling less isolated and more accepting of their problems. There has been enthusiasm for a monthly drop-in session for which funding has now been confirmed, and it is hoped that this will support people to continue with regular practice.

Mindfulness-based individual psychotherapy
While some psychotherapy trainings are specifically founded in a Buddhist/mindfulness perspective, notably core process psychotherapy¹⁵, the majority of psychotherapists and counsellors practising a mindfulness-based approach are likely to have trained in another modality and to integrate mindfulness into their usual way of working as a result of developing a long-term meditation practice and attending mindfulness groups or retreats. However, many counsellors and psychotherapists will be naturally sympathetic to a mindfulness approach, which shares the basic psychotherapeutic values of various counselling modalities (see below: ‘Similarities between mindfulness-based and other psychotherapeutic approaches’).

What makes mindfulness-based psychotherapy distinctive, most importantly, is that the therapist establishes their own regular mindfulness practice in order to be able to embody mindfulness in their relationships with clients⁶. A therapeutic relationship can be cultivated in which therapists and clients practise being with and befriending difficult emotions with curiosity, trusting the unfolding process, often by using the breath or awareness of body sensations as an anchor and a way back into presence if feelings are overwhelming. Other distinctive aspects of mindfulness-based psychotherapy are outlined in the box above.

Some mindfulness-based psychotherapists may contract to teach eight-week MBCT or MBSR courses on a one-to-one basis, either within an ongoing therapy arrangement or on their own; others are informed by mindfulness in a way that is primarily responsive to the needs of individual clients and integrated with their usual therapy approach²¹. Two examples of using a mindfulness-based psychotherapy approach on a one-to-one basis are given in the case studies (see below).

Mindfulness is not a ‘technique’ that can be learnt as an ’add-on’ to existing therapy skills after doing a workshop or two. There can be a deceptive simplicity to a verbal or written description of mindfulness practice, and some who have not practised it may think that mindfulness is something they already do: ‘After all, just being mindful of what’s going on is something any therapist can easily do, isn’t it? Surely mindfulness-based therapy is all about teaching people with real problems to be more mindful?’ It is only when therapists and would-be mindfulness teachers begin observing their own minds in regular practice that they experience just how full of distraction and conflict their own minds are habitually, and how difficult it is to be fully present and at peace²². The length of time it takes a practitioner to be ready to teach others effectively will vary from person to person, but perhaps a guideline could be the extent to which formal and informal mindfulness practice has become a way of life for them. It is only from this basis of personal experience that a teacher will be able to support and guide others through the doubts and difficulties that will inevitably arise in ongoing practice.

The benefits of mindfulness tend to accrue in a gradual and organic way with patient and sustained practice. Mindfulness-based approaches offer no quick fix to eradicate patterns of emotional, cognitive and behavioural reaction that may have been part of an individual’s way of being for many years. However, the experience of mindfulness-based psychotherapy or group courses can introduce people to fundamentally new ways of responding to life experiences and cultivating a deeper sense of health and wellbeing in their lives.

Similarities between mindfulness-based and other psychotherapeutic approaches
Mindfulness-based approaches support:

• Non-judgmental friendly awareness, authenticity, compassion and loving kindness.
• Being present and aware, moment by moment.
• Awareness of the body and sensations.
• Conscious disengagement from habitual cognitive and behavioural patterns (‘letting go’).
• Developing trust in the unfolding process of the client/therapist relationship

Therapies sharing these aspects:

• The person-centred approach rests on Carl Rogers’ core conditions of unconditional positive regard, congruence and empathy¹⁶.
• Gestalt therapy; Focusing and the concept of the ‘felt sense’, an embodied sense of moment-by-moment experience, developed by Eugene Gendlin¹⁷.
• Body psychotherapy, somatic trauma resolution, bioenergetics and other Reichian therapies; Focusing¹⁸.
• Cognitive behaviour therapy⁶.
• Concept of ‘relational depth’¹⁹.

Distinctive aspects of mindfulness-based psychotherapy

• Therapists have their own mindfulness meditation practice.
• Mindfulness-based approaches can be seen as the cultivation of co-mindfulness between therapist and client.
• ‘Non-doing’ is seen as transformative.
• Mindfulness embraces whatever is arising in the present moment, and has no intrinsic rules, expectations or limitations. It can be seen as a ‘journey without a goal’.
• Mindfulness-based approaches are especially helpful in developing confidence in working ‘at the edges’ of difficult or overwhelming emotions²⁰.

Case study: Bringing mindfulness to habitual self-judgment
The son of a disciplinarian headmaster, Adrian often started sentences with ‘I know it’s pathetic but…’ or ‘You’ll probably think I’m stupid but…’

In mindfulness-based psychotherapy sessions, Adrian was encouraged just to notice mindfully each time he judged himself harshly and to recognise how that felt in his body. Using this approach, he gradually began to bring a friendly attention to his self-judgment so that he did not convert mindful attention into another form of self-judgment and react as if the self-judgment itself was something undesirable that he needed to get rid of. As Adrian began to recognise his self-judgment as a habit and observe it without reaction, he began to experience having a choice in the present to let it go, and to have a greater sense of self-acceptance.

Case study: Using a mindful ‘breathing space’ to help a client emerge from overwhelm and process difficult emotions
Jenny suffered from deep, recurrent anxiety, which she felt was related to her mother having died when she was a baby. In talking about her feelings in therapy she tended to become tearful and full of fear and hopelessness, just like the abandoned and terrified infant she had once been. If Jenny stayed in overwhelm she would risk being re-traumatised. However, she needed to be able to work with her deeply held and restricting emotional patterns in order to realise more of her potential in life.

When a client is emotionally overwhelmed, my first priority as a mindfulness therapist is to ensure that I stay present. I need to be able to communicate a sense of calm empathic confidence that these feelings are workable and valuable. If, when I check in with myself, I become aware of feelings of anxiety, avoidance, or wanting to fix things, I need to take some mindful breaths and come back to my own present awareness before saying or doing anything with the client.

The three-minute breathing space is taught in mindfulness groups, and I use it increasingly in an adapted form in one-to-one sessions. The practice can be understood using the image of an hour-glass, with the wide top representing the first minute, in which attention is given to the whole of how things are in the present, the narrow waist, the focused attention on just the breath, and the wide base the return to an inclusive attention. I might first reassure Jenny that her feelings are okay, that they are ‘just feelings’ that want to be acknowledged, and as such are not going to harm her now.

I might suggest that she grounds herself by giving attention to her here-and-now experience of sitting in a chair, feeling the sensations of her feet pressing on the floor. I would invite her to let her attention flow up through her body, being aware of physical sensations, the breath and maybe sounds. I would encourage her to have a sense that there is nothing she needs to do right now, and that she is being completely supported. I would be mindful of everything that I sense about Jenny moment by moment – her posture, expression, sighing or shallow breathing and so on – and let this inform me about how I need to be with her.

I would invite her simply to notice whatever is happening for her in the present moment – emotions, sensations, thoughts, images – without needing to change anything. I would then suggest that Jenny allows herself to let go of all she has been noticing and bring her attention to focus on her breath alone, noticing each in-breath and out-breath, letting the breath be natural, and, when any thoughts or distractions come in, bringing the attention back to the breath for a minute. This allows a brief but powerful disengagement from the troubling emotions, and can help her to connect with her resources and a sense of restful spaciousness. Jenny can then be guided to widen her attention out to whatever is going on for her, while keeping connected to the felt sense of calmness and clarity that she is likely to have accessed in the practice. From this perspective she will usually be able to relate to her feelings in a more creative space, in which insights and realisations can seem to float into consciousness unbidden, and unexpected shifts can occur.

Since Jenny has been guided regularly through the breathing space in therapy, she is more able to bring herself out of overwhelm and feel more confident in working with difficult feelings as they arise outside sessions. The terror and pain that had been her core experience all her life, and around which an adaptive self-protective persona had been constellated, are lessening, and a vibrant sense of herself, founded in trusting her own felt experience, is beginning to emerge.

Wendy Harvey is an independent BACP accredited practitioner and hospice staff counsellor.

This article was previously published in the January 2009 issue of Healthcare Counselling and Psychotherapy Journal (HCPJ), the quarterly journal of the BACP Healthcare division. For further details about how to join BACP Healthcare or to subscribe to the journal, please contact 01455 883300 or email enquiries@bacp.co.uk

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