Clinical Handbook of Mindfulness (12 page)

itation. There are many types of meditation that can cultivate mindfulness.

Most involve initially choosing an object of attention, such as the breath,

and returning our attention to that object each time the mind wanders.

This develops a degree of calmness which, in turn, enables us to better

focus the mind on the chosen object. Once some concentration is estab-

lished, mindfulness meditation entails directing the mind to whatever begins

to predominate in the mind—usually centering on how the event is expe-

rienced in the body. These objects of attention can be physical sensations

such as an itch, an ache, or a sound, or emotional experiences as they man-

ifest in the body, such as the tightness in the chest associated with anger or

the lump in the throat that comes with sadness. Regardless of the chosen

object of attention, we practice being aware of our present experience with

acceptance.

Retreat practice
: This is the “vacation” that is dedicated entirely to cul-

tivating mindfulness. There are many styles of meditation retreats. Most

involve extended periods of formal practice, often alternating sitting med-

itation with walking meditation. They are usually conducted in silence, with

very little interpersonal interaction, except for occasional interviews with

teachers. All of the activities of the day—getting up, showering, brush-

ing teeth, eating, doing chores—are done in silence and used as oppor-

tunities to practice mindfulness. As one observer put it, the first few

days of a retreat are “a lot like being trapped in a phone booth with

a lunatic.” We discover how difficult it is to be fully present. The mind

is often alarmingly active and restless, spinning stories about how well

we’re doing and how we compare to others. Memories of undigested emo-

tional events enter, along with elaborate fantasies about the future. We get

to vividly see how our minds create suffering in an environment where

all of our needs are tended to. Many people find that the insights that

occur—during even a single week-long intensive meditation retreat—are life

transforming.

The effects of mindfulness practice seem to be dose related. If one does

a little bit of everyday practice, a little bit of mindfulness is cultivated. If

one does more everyday practice, and adds to this regular formal practice

and retreat practice, the effects are more dramatic. While this has long been

evident to meditators, it is beginning to be documented through scientific

research
(Lazar et al., 2005).

24

Ronald D. Siegel, Christopher K. Germer, and Andrew Olendzki

Why Mindfulness Now?

We are currently witnessing an explosion of interest in mindfulness among

mental health professionals. In a recent survey of psychotherapists in the

United States
(Simon, 2007),
the percentage of therapists who said that they do “mindfulness therapy” at least some of the time was 41.4%. In comparison, cognitive–behavioral therapy was the most popular model (68.8%), and

psychodynamic/psychoanalytic therapy trailed mindfulness at 35.4%. Three

years ago, we speculated that mindfulness could eventually become a model

of psychotherapy in its own right
(Germer et al., 2005).
That time is rapidly approaching.

Why? One explanation is that the young people who were spiritual seek-

ers and meditators in the 1960s and 1970s are now senior clinical researchers

and practitioners in the mental health field. They have been benefiting per-

sonally from mindfulness practice for many years and finally have the courage

to share it with their patients.

Another explanation is that mindfulness may be a core perceptual process

underlying all effective psychotherapy—a
transtheoretical
construct. Clini-

cians of all stripes are applying mindfulness to their work, whether they are

psychodynamic psychotherapists who primarily work relationally; cognitive–

behavioral therapists who are developing new, more effective, and structured

interventions; or humanistic psychotherapists encouraging their patients to

enter deeply into their “felt experience.” The common therapeutic question

is, “How can I help the patient to be more accepting and aware of his or her

experience in the present moment?”

Perhaps the strongest argument for the newfound popularity of mindful-

ness is that science is catching up with practice—the soft science of contem-

plative practice is being validated by “hard” scientific research. Meditation is

now one of the most widely studied psychotherapeutic methods (Walsh &

Shapiro,
2006)—although,
admittedly, many of the studies have design limitations
(Agency for Healthcare Research and Quality, 2007).
Between 1994

and 2004, the preponderance of the research on meditation has switched

from studies of concentration meditation (such as transcendental meditation

and the relaxation response) to mindfulness meditation
(Smith, 2004).

We are currently in a “third wave” of behavior therapy interventions

(Hayes, Follette, & Linehan, 2004).
The first wave focused on stimulus and response in classical and operant conditioning. The second wave was

cognitive–behavior therapy
, which works to change the content of our

thoughts to alter how we feel. The current “third wave” is
mindfulness-

and acceptance-based therapy
. Researchers such as Steven Hayes, the

founder of Acceptance and Commitment Therapy, discovered mindfulness-

and acceptance-based treatment strategies while looking for novel solutions

to intractable clinical dilemmas. Others, such as Marsha Linehan, who devel-

oped Dialectical Behavior Therapy, had a personal interest in Zen Buddhism

and sought to integrate principles and techniques from that tradition into

clinical practice. We are now in the midst of a fertile convergence of modern

scientific psychology with the ancient Buddhist psychological tradition.

In the new mindfulness and acceptance-based approach, therapists help

patients shift their
relationship
to personal experience rather than directly

challenging maladaptive patterns of thought, feeling, or behavior. When

Chapter 1 Mindfulness

25

patients come to therapy, they typically have an aversion to what they are

feeling or how they are behaving—they want
less
anxiety or
less
depression,

or want to drink or eat
less
. The therapist reshapes the patient’s relationship

to the problem by cultivating curiosity and moment-to-moment acceptance

of uncomfortable experience.

For example, a panic patient, Kaitlin, spent the previous 5 years white-

knuckling the steering wheel of her car while driving to work. She was

doing all the traditional behavioral strategies: She exposed herself to high-

ways and bridges, she practiced relaxation, and she could effectively talk

herself out of her fear of dying from a heart attack. Still, Kaitlin wondered

aloud, “Why the heck do I still suffer from panic?” The answer is that Kaitlin

never learned to really
tolerate anxiety itself
. She was always running away

from it. She needed the missing link that the third generation of behavior

therapies addresses—learning to accept inevitable discomfort as we live our

lives in a meaningful way.

Another arena of research that is fueling interest in mindfulness is brain

imaging and neuroplasticity. We know that “neurons that fire together, wire

together”
(Hebb
,
1949,
in
Siegel, 2007)
and that the mental activity of meditation activates specific regions of the brain.
Sara Lazar et al. (2005)
demonstrated that brain areas associated with introspection and attention enlarge

with years of meditation practice.
Davidson et al. (2003)
found increased activity in the left prefrontal cortex following only 8 weeks of mindfulness

training. The left prefrontal cortex is associated with feelings of well-being.

Increased activity in this part of the brain also correlated with the strength of

immune response to a flu vaccine. More dramatic changes could be found in

the brains of Tibetan monks who had between 10,000 and 50,000 hours of

meditation practice
(Lutz, Grelschar, Rawlings, Richard, & Davidson, 2004).

The evidence from scientific studies is validating what meditators have

long suspected, namely that training the mind changes the brain
(Begley,

2007).
We are now beginning to see
where
and
how much
change is possible.

Furthermore, the changes that occur in the brain when we are emotionally

attuned to our own internal states in meditation seem to correlate with those

brain areas that are active when we are feeling connected to others
(Siegel,

2007)—sugg
esting that therapists can train their brains to be more effective therapeutically by practicing mindfulness meditation.

Practical Applications for Psychotherapy

Psychotherapists are incorporating mindfulness into their work in many

ways. We might imagine these on a continuum, from implicit to explicit

applications—from those hidden from view to those that are obvious to the

patient.

On the most implicit end is the
practicing therapist
. As just mentioned,

when a therapist begins personally practicing mindfulness, his or her capac-

ity for emotional attunement seems to increase. Regardless of theoretical ori-

entation, models of psychopathology, or modes of intervention, the therapist

seems to be able to more carefully attend to and empathize with a patient’s

experience. The therapist’s need to “fix” problems diminishes as he or she

cultivates the capacity to be with another’s pain. Therapists feel closer to

26

Ronald D. Siegel, Christopher K. Germer, and Andrew Olendzki

their patients, developing compassion both by becoming aware of the univer-

sality of suffering and by seeing more clearly their interconnection with oth-

ers. Research in this area is just beginning (Grepmair, Mitterlehner, Loew, &

Nickel,
2006; Grepmair, Mitterlehner et al., 2007).

Next along the continuum is the practice of
mindfulness-informed
psy-

chotherapy
(Germer et al., 2005).
This is treatment informed by the insights that derive from Buddhist psychology and mindfulness practice. The therapist’s understanding of psychopathology and the causes of human suffering

change as a result of observing his or her own mind in meditation prac-

tice. Insights such as understanding the arbitrary and conditioned nature

of thought, seeing the counterproductive effects of trying to avoid difficult

experience, and noticing the painful consequences of trying to buttress our

sense of separate self, all have an impact on how we approach our patients’

problems.

Finally, the most explicit application of mindfulness to psychotherapy is

mindfulness-based
psychotherapy
(Germer et al., 2005).
Mindfulness-based therapists actually teach mindfulness practices to patients to help them work

with their psychological difficulties. A host of mindfulness-based interven-

tions are currently being developed for a wide range of clinical problems.

Sometimes the patient is taught a traditional meditation practice, and other

times that practice is customized for the patient’s particular diagnosis, per-

sonality style, or life circumstances.

Untangling Terminology

As “mindfulness” is absorbed into modern psychology and Western culture,

there is growing confusion about the term. It has come to cover a lot of

ground. At least some of the confusion could be eliminated if we used Pali,

rather than English, words. (The reader is referred to
Mindfulness in Plain

English
by Bhante
Gunaratana (2002)
for a remarkably lucid exposition of Pali terms and how they relate to mindfulness practice.)

The following is an effort to tease apart the different meanings of mindful-

ness currently used in modern psychology.

Classical concept

As discussed earlier, the Pali term
sati
, which is often translated as “mindful-

ness,” denotes “awareness,” “attention,” and “remembering.” In the Buddhist

tradition,
sati
is cultivated as a tool for observing how the mind creates suf-

fering moment by moment. It is practiced to develop wisdom and insight,

which ultimately alleviates suffering.

Psychological process

Process definitions have an
instructional
aspect—they indicate what we

should
do
with our awareness. Two process definitions of mindfulness in

clinical settings are “moment-to-moment, nonjudgmental awareness” (Kabat-

Zinn, 1990,
2006)
and “awareness, of present experience, with acceptance”

(Germer, et al., 2005). These process definitions suggest, “Look at your

moment-to-moment experience, and try to do it with a spirit of acceptance.”

Chapter 1 Mindfulness

27

Another process definition of therapeutic mindfulness, “attentional control”