Embodied integration: reflections on Mindfulness Based Cognitive Therapy (MBCT) and a case for Mindfulness Based Existential Therapy (MBET). A single case illustration.
In an earlier paper (Nanda, 2009), I put forth the argument that
the practice of mindfulness gives rise to existential-phenomenological
themes and that both practices of Mindfulness and Existential therapy
have many parallels. This paper explores how
existential-phenomenological themes inevitably arise in Mindfulness
Based Cognitive Therapy (MBCT), one of the models of 'third wave
CBT' when it includes a dedicated Mindfulness based practice for
MBCT therapists. In moving from the 'doing mode' of fixing
problems, to the 'being mode' of staying with experience,
MBCT's research in the prevention of relapse of depression for
people suffering from chronic depression offers insights into the
therapeutic aspect of mindfulness. This paper seeks to explore how
insights from Mindfulness Based Cognitive Therapy and Existential
Therapy may come together through an illustration with a case study. It
also highlights that the integration of theoretical therapy models
happens within the embodied 'being' of the therapist, rather
than remaining within the pages of textbooks. I call this embodied
integration Mindfulness Based Existential Therapy (MBET).
Mindfulness, Mindfulness Based Cognitive Therapy (MBCT), existential-phenomenological themes, Existential therapy, 'being mode', being with experience, phenomenological stance, prevention of relapse of depression, open, allowing, Mindfulness Based Existential Therapy (MBET)
Cognitive therapy (Research)
|Publication:||Name: Existential Analysis Publisher: Society for Existential Analysis Audience: Academic Format: Magazine/Journal Subject: Psychology and mental health Copyright: COPYRIGHT 2010 Society for Existential Analysis ISSN: 1752-5616|
|Issue:||Date: July, 2010 Source Volume: 21 Source Issue: 2|
|Topic:||Event Code: 310 Science & research|
|Geographic:||Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom|
With the introduction of mindfulness, Cognitive Behavioural Therapy (CBT) evolved into its 'third wave'--the first and second wave being Behavioural Therapy and Cognitive Behavioural Therapy respectively. 'Third wave' CBT therapies like Acceptance and Commitment Therapy (ACT) by Steven Hayes, Dialectical Behavioural Therapy (DBT) by Marsha Linehan, and Mindfulness Based Cognitive Therapy (MBCT) by Segal et al. (2002) all emphasise the 'being mode' of mindfulness. This paper focuses exclusively on MBCT and its rationale for utilising mindfulness for the prevention of relapse of depression.
While CBT and interpersonal therapy were considered the gold standard for treatment of depression as their efficacy was as good as anti- depressant medication (Williams, 1992 in Segal et al., 2002), they were not addressing the high levels of relapse/recurrence of depression (Segal et al., 2002). Segal et al. (2002) highlight that formidable in its implications was that those with two or more past episodes of depression had a 70-80% chance of recurrence of depression in the future (Consensus Development Panel, 1985 in ibid.). This meant the focus of treating depression also required looking at risk of relapse of patients being treated. The huge difference in risk of relapse between first time depression with no past history (22%), and those with at least three previous episodes of depression (67%) (drawing from Keller, in Segal et al., 2002) showed that one of the most reliable predictors of relapse is the number of previous episodes of depression. As Segal et al., (2002) point out, the scope of the problem had changed from treating depression to including prevention of relapse of depression.
In introducing Mindfulness for the prevention of relapse of depression, Mindfulness Based Cognitive Therapy (MBCT) challenged CBT's own fundamental assumption that negative dysfunctional thinking needs to be got rid of and replaced with positive functional thinking to combat relapse of depression. Rather, it embraced the stance of the practice of Mindfulness of 'being with' experience (Segal et al. 2002).
Some common attitudes that are valued in Mindfulness, MBCT, and Existential therapy (used synonymously with existential-phenomenological therapy) are the stance of a beginner's mind, openness to discover, allowing experience to be disclosed, suspending judgment, non-striving, letting go of any agenda of curing, fixing. All these approaches encourage 'being with' experience, and an acceptance of what is present.
Though CBT lies within the mode of 'doing', 'fixing' and 'getting rid of a problem', and Existential therapy's focus is on 'being with experience', Milton and Corrie (2000) have previously looked at commonalities between CBT and Existential therapy, and how each therapy may be able to learn from the other. They especially point out the common areas around disclosing meaning through Socratic questioning and emphasise the importance of the phenomenological attitude of the therapist rather than the therapist privileging theory whether it is Existential theory or CBT theory.
The following sections will look at the emerging phenomenological attitude in MBCT as it moves from CBT's 'doing mode' to MBCT's 'being mode', the theoretical basis of how mindfulness within CBT helps in the prevention of relapse of depression, and the rationale of the introduction of Mindfulness in my approach to Existential therapy through a case illustration.
MBCT as 'Third Wave CBT' and the Arising of a Phenomenological Stance
Mindfulness Based Cognitive Therapy (MBCT) is based on the Mindfulness Based Stress Reduction (MBSR) model. Pioneered by Jon Kabat-Zinn (at the Centre for Mindfulness at UMass Medical School more than thirty years ago), MBSR was being utilized as an intervention to help people suffering from various chronic physical illnesses and its related emotional stress. MBCT like MBSR is offered in a group setting over eight weeks (minus the full day of practice of MBSR). MBCT also adapts the MBSR model to integrate some aspects of CBT in terms of client education on depression. Both MBSR and MBCT offer the cultivation of a radically different attitude. Instead of looking for ways in which to fix the difficult problems, patients are encouraged to stay moment by moment with their difficult emotions. For it is recognized that the implicit assumption in fixing problems is that problems are the enemy and that once problems go away, everything will be fine (Segal et al. 2002). Mindfulness practice offers a new perspective in which patients who are trying to get rid of the difficulties they are experiencing, have a chance to see what it feels like to let go of the desire to fix problems, and how it feels to be in a place of non-reactivity, while bringing kindly awareness to their difficult experience. The practice of mindfulness also brings awareness that trying to fight against unwanted thoughts, feelings, emotions, and body sensations creates more tension, and conflict. Kabat-Zinn's (2005) definition of mindfulness involves four aspects. It is paying attention, on purpose, in the present, and non-judgmentally. Non-judgmentally is meant as acceptance of what is present.
As Existential therapists, we may recognize how mindfulness practice offers the cultivation of a stance more congruent with the existential-phenomenological stance of 'being with' lived experience, (both of self and that of the client) and being open to and accepting what shows itself to us, moving closer to a stance of authenticity. Spinelli notes, 'Heidegger intended authenticity to refer to the opening-up to, or ownership of that which presents itself to us.' (Spinelli, 2007 drawing from Cohn, 2002, pg 50). It offers the opportunity of moving towards integration of experience as opposed to pushing away experience or being dis-associated with our experience. As Kabat-zinn (2005) and Segal, et al.,(2002.) note, it opens us to the possibility of our freedom of responding with choice rather than from a place of reactiveness. In MBSR/MBCT we can see the emergence of the existential themes of the givens of our suffering, freedom and choice within the givens.
As Mindfulness practice encourages looking at all experience, irrespective of whether the experience is positive or negative, and regardless of its importance, for whatever emerges is considered worthy of attention, this stance is congruent with what Spinelli (2005) drawing from Husserl describes as the phenomenological stance of horizontalisation. With the introduction of mindfulness, MBCT without realizing it explicitly has moved closer to the attitude of horizontalisation utilized in the phenomenological method of enquiry. Similarly, MBCT encourages moving away from analysing experience, to noticing what emerges, thus encouraging the phenomenological stance of description rather than offering explanations. Further, in staying with noticing what is present, instead of focussing on the conceptual aspects of what the experience should be, what is expected, what should be got rid of, the mindful stance in MBCT is concerned with connecting with what the experience is, which also facilitates another rule of the phenomenological method of enquiry cultivating the attitude towards epoche, noticing our assumptions of what something should be and temporarily setting them aside or bracketing them.
As we have seen, in introducing mindfulness, MBCT has adopted the phenomenological stance of curiosity, openness, clearing a space to be present for what shows itself, and the phenomenological method of enquiry--the rules of horizontalisation, description, and epoche.
Further the recognition of the relational stance of the inseparability of body/mind another central assumption in existential-phenomenological thinking stands disclosed in mindfulness practice. In the practice of MBCT, Segal et al. (2002) note that mindfulness practice, in bringing a body focussed awareness to our emotional and cognitive experience, brings awareness that thoughts, emotions, and feelings all have sensory correlates felt in the body. This has particular relevance to the prevention of relapse of recurrent episodes of depression. Segal et al. (2002) assert that as sensory knowing is quicker than intellectual knowing (Gendlin (2003) would agree that felt sense is pre-conceptual), mindfulness also facilitates an early warning signal of mood disturbance, so it can be addressed before mood rapidly spirals downward. The awareness of the breath in the body is cultivated as an anchor, to steady oneself if looking at experience feels overwhelming. This facilitates cultivating the ability to stay with difficult emotions, a stance valued in existential therapy.
How Mindfulness helps in the Prevention of Relapse of Depression
In CBT treatment for depression, Segal et al. (2002) note that though the dysfunctional attitude scale measured success in the treatment of depression; what these measures did not show was that when the mood for those who had recovered from depression was lowered only slightly, it triggered high levels of dysfunctional thinking (themes of loss, failure, and worthlessness). It was not only that dysfunctional thinking was causing depression, but also the other way round, that sad mood could reawaken dysfunctional thinking (Segal et al., 2002). Sad mood was the context through which the self and world were being experienced. I see this similar to Heidegger's (1962) stance on mood as 'attunement' as the dominant lens or context through which we see and experience the world.
This tendency to react to small increases in sad mood with large changes in negative thinking--'cognitive reactivity'--seemed to be the crucial aspect that needed addressing to prevent relapse and recurrence of depression (Segal et al., 2002).
Importantly, neurobiological research suggested that every new episode of depression contributed to small changes in the neurobiological threshold at which depression is triggered, thus lowering the threshold. It seemed that depression was leaving a mark on people even when they got well leaving them still vulnerable to ' cognitive reactivity' (ibid.).
Further, (Nolen-Hoeksema, 1991 in Segal et al. 2002) pointed out that repeated analysis and efforts to problem solve one's way out of depression, by going over the same event or situation repeatedly and ruminating on it only increased depressive mood. A vicious cycle resulted. Depressive thinking and rumination increased sad mood. And sad mood increased ruminations and habitual negative patterns of thinking. This set up a self-perpetuating vicious cycle leading to disabling and severe depression.
Introducing Mindfulness: As a practice of 'decentering' with a difference
CBT was utilising 'decentering' a metacognitive process to help change the patient's relationship to their thoughts, to stand back, 'distancing' themselves from thoughts and feelings to evaluate their accuracy. Thoughts were seen not as objective truth or reflecting aspects of self or objective reality, but rather thoughts were just seen as thoughts. Decentering helped shift the patient's perspective on negative thoughts and feelings. It was meant to protect people from future depression. However, Cognitive therapy was using decentering as a means to an end--for changing negative thinking to positive thinking, and not as an end in itself (Segal et al., 2002).
Segal et al. (2002) utilised decentering with a difference, which was the MBSR stance. Mindfulness practice offered a practice of standing back not only from thoughts, but also from feelings, emotions, and body sensations. It involved just noticing the emerging experience, but not entering into the content of thoughts, or emotions, or offering explanations, or trying to get rid of negative thinking. It offered the 'being mode'. As Segal et al. (ibid.) note, it helped to create cognitive space in a mind which was constantly ruminating. Instead of trying to replace negative thinking with positive thinking, it offered the cultivation of an attitude which is curious, attentive, interested, enquiring, accepting, and kindly in which harsh self criticism can be just noticed as something 'I do' rather than something 'I am' (Fennel, 2004). Thoughts are seen as passing events in the mind, or as clouds passing in the sky of the mind. They are seen not as 'valid reflections of reality nor central aspects of the self' (Segal et al., 2002, p. 38). This stance moves closer to the Existential-phenomenological stance, which questions notions of a fixed or rigid self or objective reality.
Conscious aware practice to take space in 'limited capacity channel' to stop rumination
Research in Cognitive therapy showed that if the limited capacity channel of the mind can be filled up with non-ruminative material, for that period rumination will cease. Mindfulness as a conscious aware form of information processing fulfilled the requirement of taking up space in a 'limited capacity channel' (Segal et al., 2002) in the mind. Again by just noticing without analysing, it offered the opportunity to step out of ruminations. In encouraging the cultivation of the 'being mode', it offered patients possibilities and choice on how to respond (ibid.)
Provide an early warning system
Being a body focussed practice, Mindfulness practice brings awareness of the inter-connectedness of thoughts, feelings, and body sensations. The somatic correlates of distress are felt quicker than they become known intellectually. Thus these somatic correlates meet the need of any early warning system, warning of an impending avalanche of negative ruminative thinking, which could be nipped before it is too late to stop.
CBT and MBCT recognise that depression is maintained by negative self definitions which are seen as truth or reality, biases in noticing information about self with a consistent negative lens and ignoring information which is contrary to it, and ruminating on these (Fennel, 2004). However, Mindfulness offers a different perspective in adopting a gentle, accepting, enquiring, kind, and compassionate way of relating to what emerges in the body and mind, without any attempt to change it.
Segal et al. (2002, p 318) note that in introducing mindfulness to patients suffering from three or more episodes of depression, 'MBCT almost halved relapse/recurrence rates over follow up period compared to treatment as usual.'
CBT, MBCT and Existential Therapy
One central assumption common to CBT, MBCT and Existential therapy is challenging notions of a fixed and rigid self, and an objective truth, or objective reality, and instead looking at the construction of interpretations and emergent meanings. Another assumption which they share is the interconnectedness of body/mind/world. CBT therapist Padesky (1995) shows the CBT model of the interconnectedness of thought, emotions, physical sensations, behaviour and life situation as being interconnected. I see this similar to the interconnectedness of body/mind/world, or self/other as expressed by Heidegger (1962) notion of 'dasein' or being-in-the-world with others.
However, how therapy is carried out by these models of therapy is different. While CBT subscribes to the 'doing mode', both MBCT and Existential therapy subscribe to the 'being mode'. While CBT and MBCT have structured protocols for specific problems, (albeit CBT in 'doing mode' and MBCT in 'being mode' offered in a group setting), the openness of Existential therapy lends itself to a free flowing engagement and exploration. Looking at any one aspect of the self opens up the enquiry to the whole of the self-construct. It is not possible to separate the enquiry into different compartments of problems, even though only one or some of them may be the presenting issue.
Secondly, in Existential therapy there is no treatment plan, or directed goal setting. It is recognised that the exploration may open up areas that neither client nor therapist had anticipated. The stance of not knowing, and an openness to discovery of the client's being-in-the-world with others is far more textured, nuanced and subtle than the direct goal setting, problem solving stance in CBT. MBCT, on the other hand, in including Mindfulness encourages the beginner's mind and openness to discovery coming closer to Existential therapy. Even so, MBCT is couched within the medical model, after all MBSR was pioneered in UMass Medical School by Kabat-Zinn. However, paradoxically Kabat-Zinn's genius lay in speaking in the language of the medical world, while healing the Cartesian divide by calling the MBSR programme mind/body medicine! I see this as masterful and mindful. To be heard by others, we need to speak their language.
Thirdly the therapeutic relationship in Existential therapy itself is of primary importance. What therapists do in therapy is secondary to how they can be in the therapeutic relationship. The structured nature of CBT and MBCT (offered in group setting) do not have the same scope of exploring the therapeutic relationship, though in MBCT (Segal et al., 2002) recognise the importance of the therapist's own embodied way of being will have an impact on the way MBCT is offered and its effectiveness in conveying the 'being mode'.
Fourthly, Existential therapy has a whole dimension of exploring the human condition and is grounded in philosophy. The recognition of existential anxiety is a call to address the unease of life itself, to look at meaninglessness in life, it asks to take courage, and how we may take responsibility to construct meaning in our life. it recognises that life has difficulties, and it moves away from pathologising human suffering. In acknowledging and accepting the human condition, our mortality, it recognises the dilemmas of life and living. We are condemned to choose, our possibilities are available only within limitations, and to take responsibility to give meaning, purpose, and direction to our life (van Deurzen-smith, 1997, van Deurzen, 2005). This indeed comes close to the existential-phenomenological themes within the tradition of mindfulness as explored in my earlier paper (Nanda, 2009).
Mindfulness, MBCT, Existential Therapy: An Embodied Integration
As an Existential therapist, where do I stand in all of this?
I seem to have little difficulty in bringing together Mindfulness and Existential therapy as a practice of Mindfulness Based Existential Therapy (MBET). Both Mindfulness and Existential Therapy are part of me. While I am a long term practitioner of meditation, my teacher training in MBSR (at the Centre for Mindfulness, UMass Medical School, US) the model on which MBCT is based offers me the skills for teaching Mindfulness within groups. I draw from the seminal work by Segal et al. (2002) on MBCT to inform me of how Mindfulness helps with the prevention of relapse/recurrence of depression. I have no difficulty in adapting to the needs of the situation flexibly, especially if I am introducing Mindfulness to a therapy client.
For me the central aspect is an openness to enquiry, curiosity, being with experience, attentiveness, a respectful space which is a fundamental phenomenological stance in therapy, and an exploration of the existential themes of the human condition. Mindfulness enhances this for me, and from MBCT, I take the rationale for its introduction for the prevention of relapse for depression
Illustration of Therapy with John
John came to see me for help with his depression, five months after their baby was still-born in an advanced stage of his wife's pregnancy. They have an older child. John was on antidepressants, but even with the medication life was feeling much too hard to cope with.
Therapy before Introducing Mindfulness: The Unfolding of the Therapeutic Relationship and Existential Themes
John spoke of his immense sorrow and loss at the death of their child. As I listened attentively sharing the space, the silences, and offering my understanding of his pain, what felt palpable for me was the human to human connection we had. While I have never experienced loss of this nature, I am no stranger to the human condition of pain and suffering. Perhaps John sensed that I felt his pain with him.
In our second session, John expressed his grief not only of losing his child, but also of the possibility of not being able to have another child. His wife's history of difficult pregnancies and miscarriages was painful. Yet, waiting much longer with the biological clock ticking away for his wife at age 40 years seemed equally painful for him. He was distraught. I acknowledged his distress and stayed with his experience.
His next statement came as a surprise, 'You must have had other people come to you with similar issues. In your experience, what do you think we should do, should we try for another baby?'
I realized John thought of me as an expert who could solve his problem for him. He was confronted with existential issues. Death of baby, time ticking away, loss, uncertainty about the outcome of another pregnancy, anxiety, choice, and responsibility (Heidegger, 1962). The disclosed existential themes revealed the dilemma of the human condition in his personal predicament. The Existential-phenomenological approach sees dilemmas as the human predicament, the difficulties of life and living, and does not pathologize them. They are welcome, as they offer possibilities for discovering meaning and purpose within the limitations of life.
I replied, 'You are asking me to choose for you whether you and your wife should try for another baby?'
John: 'What do you think?'
Jyoti: I can see it is a difficult situation, and choosing one way or another is really hard. It is a real dilemma. I really don't know what the right choice is for you John. What do you and your wife want?'
John looked crestfallen.
John: 'That's not very helpful. If I knew I wouldn't ask you.'
Jyoti: You're looking for an answer from me, and I am not telling you what to do! (Pause) I can understand you are perhaps disappointed and perhaps annoyed with me. But you are assuming that I should know what the right choice is for you.
John looked perplexed and thoughtful.
Jyoti: (Silence) 'Perhaps the answer will emerge, as we find greater clarity about what is really important for you.'
Over the course of therapy, my feeling comfortable with the not knowing, and moving away from being the expert who knows the 'right' answers from the 'wrong' ones and someone who provides explanations of what is 'wrong' and knows how to fix it, perhaps facilitated for John a greater comfort in staying with his own not knowing, and uncertainty.
In subsequent sessions, this opened up another area of exploration, 'what' and 'how ' someone should be. For John 'normal' meant being like others, and having what others have. This stance is similar to Heidegger's 'The They' (Heidegger, 1962). To this extent, not having a second child felt to him like a personal failure, especially when he saw others with two children.
I empathized with him, 'It feels like a reminder yet again, and of course it is painful. But I am not sure I understand why you see this as personal failure'.
This opened up the exploration of the self-definition of being a failure. It meant not being able to control outcomes.
John: 'I didn't do enough to save our baby'.
Jyoti: (after a silence, then saying softly) 'Didn't do enough to save your baby?'
John: 'I should have saved our baby, somehow.'
Jyoti: 'Of course, you wish you could save your baby. So do I. But I am still not sure I understand why you see this as personal failure.'
John: 'It is pathetic, I feel helpless that as a father I couldn't somehow save our baby'
Jyoti: (after a silence saying softly) 'Of course, it feels helpless. Both of us wish it had been different. But can either of us control outcomes in matters like birth and death, which are beyond our control? Can either you or I know when and how we or our loved ones are going to die?
The existential theme that we have choice only within the givens of our human limitations (Heidegger, 1962) informed my intervention. I acknowledged our shared desire for life, and our shared helplessness of what is beyond our control- birth and death. This intervention was possible within the strength and quality of our relationship. Without the relationship itself, it could sound quite clinical. Our being together with the pain and suffering of the human condition, sharing the space and the silences allowed John to reflect and re-consider what was beyond our control, that possibilities arise within limitations.
John looked forward to our meetings, and so did I. Though never schooled in philosophy, John had a wonderful capacity for reflection, which in turn encouraged me to explore. In our relationship, perhaps John experienced care, kindness, empathy, respect, acceptance, warmth, and the shared place of 'both', 'us' and 'we'. The implicit message I was conveying was that I could accept John just as he was. Acceptance of his personhood did not prevent me from challenging his 'sedimented' beliefs. Our relationship could be seen close to Buber's I-Thou relationship. It offered inclusion of John's way of being by me, while also confronting him with my own being (Buber, 1958; Friedman, 1999).
Session after session, we explored existential themes in relation to his lived experience. In exploring his self-definitions around failing, John realized that as far back as he could remember he felt this way. His father was domineering, and John had been given little choice. His father had even chosen the profession in finance for him, though he had wanted to be an artist. As John began to get in touch with his feelings, he wanted to change his job and become an artist. We explored the consequences of such a choice. John realized that though he did not like his job, he liked his current life style. He decided that he would stay, but with a difference, now he was choosing and that felt better. He was recognizing that choice, consequences and responsibility went together. The existential notion of time was also revealed that the present contained the past as it looked towards the future (Heidegger, 1962). He needn't be a passive victim of his past. He could give direction to his life.
At work, John recognized how the financial markets going up and down affected his moods like a 'yoyo'. However, as we explored, even here he began to realize he had choice. Successful/unsuccessful deals need not be equated to self-definitions of worth/worthlessness of his personhood, albeit that was how the work place utilized language. John had choice in how he defined himself, and these were valuable insights for him.
After twenty-four sessions over seven months into therapy, John seemed to be already defining himself differently and less self-critically. At work, he began to question his colleagues in meetings. Earlier when he was questioned, he invariably believed that he was at fault, and accepted criticism from others without questioning or exploring it further. In his personal life, he began to stand up to his father, and also started expressing his needs more freely to his wife.
In our relationship, I often felt admiration for John, for his capacity for philosophical reflection, the silences in which I could sense that he was actively recreating meaning for himself through our dialogical encounter, for his openness to be forthcoming in wanting to address his issues, and his ability to take back into his life what we had discussed.
Revisiting the initial concern
It seemed that John was in a more robust place as compared to before. However, there seemed to be a dramatic shift for him after his baby's first death anniversary. The week before the death anniversary, he seemed in a stable place, and yet the week following the anniversary he said it felt like he was back in the same dark and hopeless place as before. I acknowledged the sadness that he was experiencing. He expressed concern about the dramatic mood swing that he had experienced following the anniversary, and wondered if this was how it was always going to be. He asked, was there nothing I could teach him in terms of a 'method' that could help him to not slide back?
I knew that feeling sadness at an anniversary was not unknown, or uncommon. Yet, the way John described his downward spiraling of mood, I wondered if this was 'cognitive reactivity' triggered in sad mood in the way that MBCT speaks of. Mood as context in MBCT resonates with the Heideggerian notion of mood as 'Befindlichkeit' the German term which 'designates our moods as ways of finding ourselves in the world' (Polt, 1999, p64). Our experience of reality is disclosed through the attunement of our moods. However, drawing from Heidegger's 'Beingand Time', Polt notes that
not all moods are equally disclosive. Someone may be trapped in an inauthentic or inappropriate mood. In this case, mood still shows things, but it shows them in an overly restricted way. This is why we need to gain some control over our moods (175/136). Our goal should not be to escape from moods altogether, but to find the right moods. (One wishes Heidegger had said more about how to do this.)
(Polt, 1999, p.66).
That MBCT recognized the importance of monitoring mood, and of mindfulness in providing an early warning system of an impending avalanche of a dark mood is noteworthy. My understanding of the ' right moods' (Polt, 1999) is one that opens and widens rather than restricts disclosing. I believe that mindfulness is one such way that could offer us this possibility of 'doing' which opens us to our 'being'.
Here was John asking for a 'method' to re-orient his sad mood. The 'method' that I could offer him was 'mindfulness'- one of being present to all his feelings, thoughts, body sensations within his situational context in a spirit of enquiring, welcoming and accepting.
Reflections on introducing mindfulness
I was aware that the Existential approach is technique averse. I needn't have offered mindfulness. I could have stayed with John's distress in the manner that I had, and clearly that was helpful to John. Yet there was this whole body of research that I was aware of. Should I deny John a practice that I believed would be helpful?
What weighed for me in favor of offering Mindfulness to John was my belief that mindfulness would offer him a skill, as it was body focused, of detecting small sensory correlates of mood changes in the body before the mood spiraled out of control, while something could still be done about it. Reflection was already a part of our work together; a body focused practice would be new.
As I did not in any way wish to reduce the time we had together for our usual therapy session, I felt if I was to introduce mindfulness, it would be as an add on. I recognized that this introduction would mean the changing of many boundaries (not least that I would be mindfulness teacher and therapist) and it would have an impact on the therapeutic relationship, and on the process of therapy. There was also the possibility that the practice of mindfulness might not go down well for John. However, I felt that we had a strong enough relationship and John could feel free to let me know if mindfulness was not for him. I also believed in my own capacity to be open to hear John's displeasure regarding it, were it to not suit him.
I spoke to John of Mindfulness and its efficacy in MBSR/MBCT. John seemed enthusiastic to try out mindfulness. He said he trusted me and would be happy to try it out. I was open and honest in disclosing that it was the first time I was utilizing Mindfulness in a therapy session. It also was an opportunity for him to choose whether to try it out or not. I said that since this was my very first time of offering it to any one in a therapy session, I too would be learning from it. I would not charge him for the extra time of 30 minutes we spent on mindfulness before the start of the session, as both of us were venturing out into unchartered territory. At this John expressed satisfaction, and gratitude.
This was to be a new phase in therapy.
Introducing mindfulness in the session
At the next session, I introduced body focussed mindfulness of the breath to John. This involves noticing the body sensations associated with breath and breathing. It is a practice for training attention and focus, as well as recognizing every time a thought, feeling or emotion arises, noticing them with acceptance, and coming back to the breath in the body. This was a departure from how Mindfulness is introduced in MBSR/MBCT, which introduces Mindful eating of a raisin, and the body scan first. While MBSR and MBCT programmes require practice commitment for a minimum of 45 minutes a day, I sensed that I would need to be flexible with John. I asked him what he felt was a realistic amount of time that he could put aside for a daily practice. John felt that he could commit to ten minutes for a regular daily practice. I agreed to what he was able to commit to with the view that gradually if he could find more time, he could increase the duration to whatever felt comfortable to him, but that he would stick to a baseline of ten minutes of practice everyday. Before the end of the session when I asked him how he had experienced the mindfulness practice, he said he felt relaxed in the body, and felt calm.
The following week when we met, I was curious to know how he had experienced the practice. I was expecting John to say, like many people do, that it was hard to maintain focus, that he felt bored and sleepy. However, John replied that he had found the practice very useful. It gave him time to sit with himself, allow thoughts, feelings, emotions to emerge, and that it felt such a relief not to have to fight with them to get rid of them, that they could just be present and accepted. He also found focusing on the breath calming and relaxing. I was surprised at the way in which he described his experience, as though he was an experienced mindfulness practitioner.
That he was commenting on the letting go of the conflict or struggle of trying to get rid of difficult emotions, seemed to me to be almost unbelievable. This in just ten minutes of daily practice over the period of one week! I was somewhat awestruck by John's ability to take this practice on board so seriously, albeit for ten minutes a day.
While the MBSR/MBCT programme introduces mindfulness of scanning the whole body, mindful movement, and mindful walking, John expressed a lack of interest in the body scan. The size of the room did not permit the practice of mindful movement, and mindful walking, (though we practiced mindful walking in the corridor, our usual path to enter and leave the room, once on a day when I knew we would not make a spectacle of ourselves!) So the main focus of our practice was on mindfulness of breathing. This extra time of 30 minutes with Mindfulness continued for nine weeks, before a vacation break. By the time it was time for the break, John was practicing ten minutes of mindfulness regularly on a daily basis. He reported that he felt that he was using his breath as an anchor at times when he was feeling stressed at work, and in being with his breath, he felt calmness. He also expressed that he felt a greater clarity about the connectedness of his thoughts, emotions, feelings, and body sensations. He could experience body correlates with thoughts, and emotions, and locate the body sensations with the arising of thoughts, and emotions. He also reported recognising how standing back just a little bit from his thoughts enabled him to see thoughts as thoughts, rather than as 'facts' or 'truth' or 'reality'. He was developing 'metacognitive awareness' as described by MBCT therapists Segal et al. (2002). He recognised how often he was 'constructing and imagining scenarios' as though they were real, and reacting to these imagined constructions.
At work, when things were getting too stressful with deadlines, he could take a few moments just to connect with his breath, and create some space in which to see things more clearly. Feeling the breath in the body, feeling the body sensations of tightness of muscles in his chest, associated with the anxiety, and dread of the situation, allowed him the embodied experience of anxiety, and the understanding of the inter-connectednes of how we think and construct meaning, with our emotions, feelings and body sensations. With bringing awareness to the body sensations of tightness of muscles, and staying with them, John was able to ease the body tightness, and stress. Such moments of calmness in the body and mind also enabled him to re-evaluate the situation of his work. For John to have an embodied experience of the relational aspect of the construction and definition of his 'self', and 'reality' felt freeing. John began to experience lightness in everyday living.
John's newfound confidence seemed to be visible by the way in which he walked, and how he carried himself in a more purposeful manner. John said that despite the ups and downs, he felt able to embrace his negative feelings. He was able to monitor when his own habitual self critical stick showed up to beat him up. This meant that John now did not automatically lead himself onto self-critical self-definitions.
Coming off antidepressant medication
About five months after the introduction of mindfulness, John asked if I thought he could give up his anti-depressants, as he seemed to be coping well. I asked him how he felt about giving up his medication, and explored the implications of giving it up. John said he was feeling competent at work, and things felt under control. I asked him to consult his GP if he wanted to come off the medication. John got the go ahead from his GP. However, it was another five months before he started coming off the medication as he was head hunted for another job, and this meant a stressful time of professional transition ahead.
John started tapering off the medication under supervision from the GP. As the effect of the medication started waning, John reported experiencing his feelings with greater intensity, with greater nuances to them. The irritations and frustrations had greater intensity, but so did the pleasures and the joys. Colours seemed more vivid, and sharper. What he was noticing had a wider range to them. While he was still coming off his medication, it was his baby's second death anniversary. We had explored what it might mean for him, to come off his medication at such a time. John felt alright about coming off his medication despite the forthcoming anniversary. The week after the anniversary, when we met, John reported that he had felt sad, but that he had allowed the sadness to be present. He felt that in embracing his sadness, he could also let go of it in a way that he had felt unable to do so earlier. It was an intensely moving moment when he said,--'If anything good has come from this death, it is this opportunity to evaluate my life, in a way in which I would never have done.'
John came off his medication fully. Some months earlier, John had expressed how much the practice of mindfulness had made a difference to him. It was also the time when I was offering workshops on mindfulness and asked him how he felt if I spoke about our work together on the introduction of mindfulness in therapy, keeping the confidentiality of course. John gave me written permission to speak or write about our work together. He also offered to help in any way which might facilitate furthering writing or research on this subject, and offered to write about his experience.
After John had come off his medication, he asked me if I had written about introducing mindfulness in therapy for publication. To his query, when I said I had not yet written it, John felt free enough to let me know that he was disappointed with me!
The client's Perspective
It is not often that we get a qualitative account of the client's written perspective on the experience of therapy. For that reason alone, it becomes worthwhile in offering it as a small contribution to the body of research on Mindfulness in individual therapy.
Here is John's experience in his own words:
I remember quite clearly when you first made reference to Mindfulness as an option that we might try: it was the week of the anniversary of the birth/death of (baby's name).
With the work that we had done together over the preceding six/seven months, I had been feeling happy and confident again. The anniversary unexpectedly pulled me down again, and I can remember expressing a frustration to you that I did not have a mechanism to deal with such situations. I felt vulnerable again notwithstanding that I had been feeling so much stronger--it was as though I was kidding myself, and the grief could always come back and consume me if it wanted to.
Given the work we had done, I felt completely trusting of you, which I think was important to me if I was to consider trying something very different.
You positioned it very well- it was an option. There was no pressure to try it, but it did appear it could provide me with something--a tool, if you like, to allow me to help myself.
For me, the simplicity and naturalness of Mindfulness instantly held appeal for me. The fact that it was a long standing technique that had been developed in an American university to help people, gave it credibility, and a sufficient sense of mainstream for me to consider it both safe and workable.
The other key factor was your willingness to make additional time available to learn the Mindfulness--it meant it could be done as a supplement to the counselling which was important for me as it again felt that this was a supplemental help rather than a replacement for the counselling that had preceded and had helped me; it encouraged me that you felt that it warranted time and effort to be learned; and the very fact that you were offering to make more time available without seeking additional payment sent a very encouraging message to me. It felt as though you were tailoring a solution to my needs, and that you were willing to be flexible in your approach to help me.
You did warn me that the impact of Mindfulness could be life changing, and I am delighted to say that you were right. It has allowed me to understand myself in a way that I had never imagined. It has given a way of living with myself, and the consequence of that is that I am no longer "beating myself up" about my reactions to situations no longer despairing at myself for feeling a certain way.
The focus on living in the present is very important to me. I had already learned from our counselling that I had a propensity to either be constrained by the past repeating itself; or by my forecasting pessimistically about the future. Very often this meant that I was not allowing myself to enjoy what I was actually doing in the present, and what is more, I think that deep down I recognized this problem, which made me feel worse about myself. To be able to bring myself back in the present has been a liberating and uplifting feeling for me.
Mindfulness has given me the ability to create just enough space between me and thoughts/feelings to be able to recognize them, and the combination of the space and recognition has allowed me to either simply accept them and move on, or it has enabled me to take action in order to support myself, as a step towards moving on.
It is not just my life that has been improved by Mindfulness, but those around me. My wife in particular, and also work colleagues, have all remarked directly or indirectly how much lighter and happier I have become. I can feel it in their responses to me, and that in turn, has an encouraging and uplifting feeling for me.
Most importantly, Mindfulness is providing me with a tool for the remainder of my life. At some stage, the counselling will stop, but Mindfulness will continue.
For me, the counselling experience and the Mindfulness has actually become a benefit--a positive to emerge from the lowest point in my life. Losing (baby's name) and then the experience of becoming depressed have been horrendous, but nevertheless, it does now feel incredibly that something good has emerged that will make the rest of life better.'
John was with me in therapy for just over two years. It is now two years since the end of therapy. A year ago, I was delighted to hear from him. He wrote, 'I am well. Mindfulness would certainly be useful for my colleagues right now!' (He was referring to colleagues in the financial sector during the economic downturn).
This paper highlights the theoretical rationale of how Mindfulness helps in the prevention of relapse of depression in Mindfulness Based Cognitive Therapy (MBCT) and how I see the applicability of bringing together insights from MBSR/MBCT albeit with many adaptations to flexibly integrate Mindfulness with Existential therapy as Mindfulness Based Existential Therapy (MBET). The integration for me is seamless within my own being. I consider the therapeutic relationship as central to our work with clients in therapy. It is within the centrality of the therapeutic relationship that Mindfulness is offered, as I allow myself to be informed of valuable research from MBCT.
Contrary to the position of many Existential therapists, I am not averse to introducing the 'technique' of Mindfulness in my therapy work. Had I not introduced mindfulness, perhaps John may have still been helped. However, by not offering mindfulness, I would have denied him the benefit of research knowingly, and that doesn't sit well with me. Nor would I have ever known its possibilities for John.
It is my view that perhaps, we as Existential therapists need to re-think what we mean by 'techniques'. Every training requires some methods. Psychoanalysis utilises the method of free- association and evenly hovering attention to offer a non -judgmental space in which all thoughts, feelings, emotions can be expressed. Existential therapy offers the rules of horizontalisation, description, epoche in the phenomenological method of enquiry. If Mindfulness offers 'techniques' to cultivate acceptance, loving-kindness, compassion, spacious awareness, and presence, I wonder why we as Existential therapists are so averse to including it as a practice and in our training programmes?
Mindfulness Based Existential Therapy (MBET) is part of who I am, as both Mindfulness and Existential therapy are integrated within my own being, and remain in process... While I offer Mindfulness only as an option to therapy clients, many clients who now approach me do so as they are interested in both mindfulness and therapy. Mindfulness Based Existential Therapy (MBET) is now part of the paid session.
Significantly, I would like to stress, the therapist's embodied stance of 'being with' and 'openness' to the client's lived experience is the crucible within which Mindfulness practice is offered. I sit with Shunryu Suzuki's words, 'In the beginner's mind there are many possibilities, but in the expert's there are few' (Suzuki, 1970, p21).
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Jyoti Nanda CPsychol is registered as a BPS/HPC Chartered Counselling Psychologist, UKCP Existential Psychotherapist, and is MBCAP accredited. She is a Visiting Lecturer at Regent's College School of Psychotherapy and Counselling Psychology, London, where she teaches on the Doctoral Programme in Counselling Psychology. She has studied in India, the UK, and USA, and has travelled widely. Her clinical experience includes working with patients in an NHS hospital and in Private Practice. A long term practitioner of meditation in more than one tradition, Jyoti's research interests are centred on meditation, mindfulness and its effect on the therapeutic relationship, and cross-cultural therapy. She conducts workshops and short courses on mindfulness and its relationship to psychotherapy in general, with an emphasis on the co-created relational stance that underpins Existential therapy in particular.
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