Mindfulness based-third wave CBT therapies and existential-phenomenology. friends or foes?
This article explores the similarities between Existential
Phenomenological Therapy (EPT) and Mindfulness-based third wave
Cognitive Behavioural Therapies. It is argued that EPT and Cognitive
Behavioural Therapy (CBT) share common philosophical and ontological
principles, but that they differ in important ways, particularly with
regard to how their therapeutic objectives are pursued and to their
methodology. These differences are largely bridged in the third wave
developments of CBT. It is hoped that acknowledging the similarities,
rather than just focusing on the divergences may facilitate a productive
and stimulating debate on the nature of therapy and of psychological
wellbeing over and above the adherence to modality-driven
Existential Phenomenology. Cognitive-Behavioural Therapy. Mindfulness. Third Wave CBT. Attention. Acceptance. Awareness. Meta-cognition.
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 Canadian Subject Form: Cognitive-behavioural therapy|
|Geographic:||Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom|
When a few years ago I started working in the NHS as a newly qualified counselling psychologist, I found myself expected to practice in a time-limited, goal-oriented, evidence-based manner. Flyers were affixed on the walls of the hospital where I worked warning psychologists that legal action may be brought against those not offering clients CBT, the therapeutic approach most strongly supported by that NICE endorsed, gold-standard of experimental studies, the randomised control trial. I therefore embarked on a hasty if reluctant learning curve which to my initial surprise has proved rewarding in a variety of ways. One of the important factors that is often forgotten in the current CBT bashing is that for all its purported siding with psychiatry and the establishment, CBT as a talking therapy is still a more desirable alternative to pharmacological intervention in the management of mental health difficulties. Had CBT not adopted some of the parameters, language and methods of scrutiny demanded by the NHS and public sector service providers, it is unlikely, particularly in a climate of budget cuts, that a 'talking cure' would have been considered as a credible alternative to medical treatment and that psychological intervention would have received the recent amount of government funding and the media exposure that has ensued. However that is not to say that there are not problems with the state supporting one therapeutic modality to the exclusion of all others or that CBT is above criticism or refutation. Like all therapies it can be badly practiced, misrepresented and misappropriated and because of its pragmatic focus, CBT, in the wrong or inexperienced hands, can perhaps more easily than other forms of therapy degenerate into a mechanical, invalidating and superficial collection of soulless interventions. Indeed technique can be ineffective at best and even dangerous if applied in a vacuum and divorced from a solid philosophical grounding and sustained grappling with epistemological, ontological and sociological questions on the nature and role of psychotherapy and on what it is to be human.
It is therefore important to distinguish between the dubious use CBT is being put to in current public policy and the evolving practice of CBT, which reflects the wealth of research, reflection and commitment of many of its practitioners (House and Loewenthal, 2008). Although the accusation of being a therapeutic magpie is often levied against CBT, in my view its openness and flexibility constitutes a merit and an adaptive advantage in the therapy world. Not only does CBT continue to evolve through the interplay of theory, research and clinical observation (Mansell, 2008), but also it has consistently remained receptive to assimilating ideas and strategies from other therapeutic approaches and research findings, particularly in the fields of neuroscience and information processing, provided they fitted in with its basic conceptual assumptions. As a result, the umbrella of CBT now covers a group of heterogeneous psychotherapeutic interventions linked by common philosophical principles. These include therapeutic practices, such as Acceptance and Commitment Therapy (Hayes et al, 1999), Schema Therapy (Young et al, 2003) or Compassion-based therapies (Gilbert, 2005), that are much richer and more complex than some manualised, simplified versions of CBT such as the one that at this stage seems to be offered by the government-supported IAPT programme (1).
It was therefore heartening for me as I descended from my uncompromising, rather purist existential pedestal and reluctantly approached CBT, to find within its confines an extremely vibrant movement of research and investigation which seemed to give rise to the adoption and refinement of promising therapeutic strategies. In addition I also identified a number of important commonalities with Existential Phenomenological Therapy (EPT), particularly in what are described as the third wave, primarily mindfulness-based, cognitive behavioural therapies. This made it possible for me to start the process of grafting elements of CBT onto the bedrock of my existential phenomenological training thereby enriching my therapeutic work without renouncing what to me are the EPT-defined fundamentals of psychotherapy.
My focus in this article is on this third wave, mindfulness-based therapies. The view I put forward is that rather than adopting a dismissive, closed off stance against CBT regarded as a monolithic, static entity, as EPT therapists we might benefit from engaging in a dialogue in which the similarities as well as the differences between the two approaches are debated. One of the things that this process would reveal is that principles that are foundational to the existential phenomenological approach also inform especially the newer developments in Cognitive-behavioural therapies. In addition, strategies developed particularly (but not exclusively) within the third wave, mindfulness-based CBT could be of use to enhance the process of exploration of the client's worldview that is at the core of the existential-phenomenological therapeutic project. Such openness to debate, influences and cross-fertilisation in my opinion can only enrich the process of therapy and improve the outcome of managing psychological distress and enhancing people's quality of life. These after all must be our ultimate aims as therapists over and above rigid adherence to modality-driven, pre-determined and inflexible sets of theoretical principles
The third wave cognitive behavioural therapy developed as an elaboration of the second wave CBT. This in turn added the cognitive element to the first wave behavioural therapies based on B. F. Skinner's work. Essentially the second wave CBT, started by A.T. Beck for the treatment of depression as an alternative to the unfalsifiable tenets of psychoanalysis, attributes a pivotal role to thoughts in functioning and 'psychopathology'. As a result it focuses on helping clients review and change the content of their thoughts in order to, in turn, alter the responses from the other interconnected areas of functioning, the emotional, physiological and behavioural. The emphasis, as in EPT (2), is on helping clients become aware of their current conscious experience of meaning-making contrasted with the psychoanalytic focus on the therapist's interpretation of the client's unconscious motivation and past experience (Mansell, 2008).
The central assumption of CBT is broadly constructivist in that it is not events that are believed to trigger emotional and behavioural responses, but rather the individual's appraisal of those events. In other words, as in EPT, the meaning clients attribute to their experience is central to the therapeutic work.
This appraisal is related to the person's concept of themselves (e.g. I am vulnerable, I am useless), others (people are hostile) and the world (a dangerous place). Such core or schematic beliefs are thought to form as a result of the interaction between innate traits and early environmental experiences. The more sedimented and rigid these core beliefs are the less flexible and adaptive the individual's responses to a changing environment are going to be. In cases where the core beliefs are on the whole functional and where as a result the client's problems are less severe and enduring, more superficial cognitive process such as assumptions and automatic thoughts are considered to be implicated in the onset and maintenance of emotional distress. The therapeutic work in these latter cases then consists in helping clients challenge the content of those thoughts. CBT is phenomenological in that it aims to bring to awareness and describe an individual's experience in all its facets, the triggering event, the thoughts, emotions, sensations and behaviour that followed. It regards knowing as always incomplete and certainty and absolute control as unattainable. It promotes a sceptical, tentative and provisional stance towards one's thoughts, beliefs and hypotheses about reality as we experience it and is fundamentally pragmatic in its emphasis on questioning and testing sedimented and habitual ways of relating to ourselves, others and the world (Leahy, 2003) (3).
Both CBT and EPT are strongly collaborative and both value the therapeutic alliance. However, whereas in EPT the relationship between therapist and client is regarded as the fundamental vehicle of change, in CBT a viable therapeutic alliance is a necessary, but not sufficient condition for positive outcome (although it might in some cases and for some individuals be sufficient). In addition, whereas CBT is directive and focused on the active therapeutic pursuit of change, EPT aims to change as a by-product of the in- depth exploration and clarification of the individual's way of being in the world. In a nutshell it could be said that because of the emphasis on techniques, CBT is a 'doing' form of therapy, whereas EPT priorities 'being' qualities. These two frameworks differ further in how human distress is conceptualised, one favouring a discourse based on medical diagnostic classification (4) and the other on humanistic descriptions of problems with living.
Third Wave Cognitive Behavioural Therapies
Mindfulness-based third wave cognitive-behavioural therapies depart from the second wave in their emphasis on changing not so much the content of thinking, but the individual's relationship to their thoughts and to their experience as a whole. Mindfulness, an ancient Buddhist practice, is a way of paying deliberate, non-judgemental attention, moment by moment to whatever comes into awareness. It is the core practice of all these approaches in that it fosters awareness, attention control and decentring, the three fundamental skills needed to change habitual patterns of reaction to one's experience. Decentring refers to the ability to observe one's experience without reacting to it and to come to see one's thoughts as transient, subjectively generated phenomena, rather than objective reflections of reality (Safran and Segal, 1990). An important shift from second to third wave CBT is therefore from working on the degree of belief a person has in their thoughts to changing the way they respond to their internal and external experience including thoughts, emotions and physical sensations. It is the subject of current debate whether this departure from one of the core assumptions of classic CBT could legitimately be regarded merely as a development or whether it should be construed as an actual schism. Indeed as well as the shift from cognitive content to process, there are two other radical departures from classic CBT: an increased emphasis on experiential rather than cognitive functioning and a diversion from the pursuit of a better, asymptomatic future in favour of the acceptance of the present moment, as troubling as it may be. However the third wave remains underpinned by the same theoretical assumptions of the second wave: that experience is cognitively mediated and that cognition is a major contributing factor to psychological distress (5). In addition, the third wave has assimilated and elaborated foundational findings, understandings and methods from the second wave such as the use of Socratic questioning (6), the nature and effects of avoidance and resistance, the role of safety behaviours as an avoidance strategy and an emphasis on psycho-education. Both the second and third wave CBT share the principle that the mind is complex and that it needs training involving the development of specific skills to function at its best. This emphasis on the didactic aspect of therapy is one that is not shared by EPT.
The quiet revolution conducted by third wave proponents evolved over many years with Marsha Linehan's Dialectical-Behaviour Therapy for people with Borderline Personality Disorder leading the way (Linehan, 1993). Its seismic impact within CBT, but also psychotherapy in general, has however become obvious in this country at least more recently with a treatment programme for chronic depression, Mindfulness- based Cognitive Therapy, MBCT. This was based on the finding that it is not so much negative thinking that is implicated in the re-occurrence of depression, but rather it is the relationship people establish with their changing experience, particularly low mood, that transforms a passing dip into a full blown depressive episode (Segal et al, 2002). Typically previously depressed people seem to try and extricate themselves from these mood dips adopting a discrepancy based, self-referential, conceptual mode of processing--'why am I not happy, I should be happy, what's wrong with me, where have I gone wrong in my life' and so forth. This conceptual mode of processing a mood state prevents it from passing, as it otherwise would, by keeping it in working memory. It also amplifies it by focusing and maintaining attention onto the thoughts rather than onto other aspects of the person's experience as it unfolds moment by moment.
Mindfulness became the core practice of MBCT as the therapeutic intervention aimed at helping people engage in a different, healthier way with their experience shifting the focus of intervention from the content of thinking to the processing not just of thoughts but of experience as a whole. Mindfulness is also the therapeutic pivot in other third wave therapies for every possible clinical presentation encompassing all diagnostic categories from the so called 'anxiety disorders' to substance abuse, problems with eating to psychosis, chronic fatigue and trauma (7). Largely as a result of a massive and mostly rigorous research effort, Mindfulness has captured the attention of the psychotherapeutic world in an unprecedented way and is rapidly becoming one of the most investigated, published, discussed, and widely adopted therapeutic practices of all times establishing a degree of influence that goes beyond the specific confines of cognitive therapy. Through the adoption of mindfulness CBT has provided tremendous impetus to the adaptation of Eastern Buddhist philosophical principles underpinning this meditative practice in the particular context of Western psychological intervention (8). In doing so CBT in its third wave has evolved in ways that in my view align it more closely with EPT. At a practical level, mindfulness-based interventions are likely to deepen the therapeutic relationship (9) and facilitate the exploration of the clients' way of being in the world, the two key aspects of EPT. In addition, by focusing on the commonalities, EPT may take a more engaged role in the CBT-dominated current discourse on psychotherapy, thereby claiming for itself a more prominent position than it currently seems to hold.
What We Talk About When We Talk About Therapy
People on the whole seek therapy because they want assistance with changing something about themselves or their lives that causes them distress. The fundamental premise of therapy is that, although it may be difficult and in some cases impossible to change external factors, it is possible to change our responses to both internal and external stimuli. Both CBT and EPT regard cognitive mediation, how we make sense and process experience, as the locus of change. Whereas the content of thinking is the focus of CBT, the third wave cognitive therapies focus on helping people change their relationship to thoughts and experience and identify four common unhelpful reactions: avoidance, rumination, judgment and unaware immersion. Mindfulness combined with reflection on the practice of being mindful reveals meta-cognitive insights on the constructed nature of experience. This combination of the experiential with the conceptual modes of processing the sources of distress has the potential of greatly facilitating the therapeutic work. In the next section I shall focus on three foundational aspects of mindfulness: acceptance, attention and awareness.
One of the most important changes brought about by the introduction of Mindfulness within the cognitive behavioural therapies concerns how therapeutic change is pursued. In CBT proper, change is on the agenda and the therapeutic journey keeps a clearly defined operational outcome as a goal firmly in sight throughout (i.e. what would it mean in practical terms for you to feel happier? What would need to happen for you to know that you are happier?). In the MBCTs on the other hand the key to change is not in its active pursuit, but paradoxically (10) in the acceptance of what is. This is a fundamental shift, which has repercussions for the whole therapeutic enterprise. Acceptance is not the same as resignation in that it involves an active stance vis-a-vis experience. It also opens up a different way of relating to one's internal state and to others. To feel that it is possible and indeed desirable to stay with whatever occurs no matter how aversive it may feel without judgment and that another person, the therapist in this case, is willing to be with us just as we are, may, for some people, be a novel and profoundly revelatory experience as existential and humanistic therapists will know.
Accepting pain, both emotional and physical, is not easily done, as we naturally tend to try and avoid it. In cases where avoidance is not possible we brace against the pain. Both avoidance and resistance have been shown to compound the problem in distressing presentations. People with positive psychotic symptoms for example often struggle in vain to suppress them. After being trained to respond mindfully to their hallucinations or delusions and to accept their occurrence without judgement, it was found that although the frequency and intensity of the hallucinations remained unchanged, the participants' level of belief in their symptoms decreased and with it the distress related to their disturbing experiences. Importantly the incidence of hospitalisation as a result decreased dramatically to half that of the control group (Bach and Hayes, 2002).
In order to be able to accept what is, one needs to be able to direct one's attention to it and then to remain conscious of what occurs. Much of what we do is automatic as a result of learning. Whereas this can be highly advantageous, it can also cause problems, as it is the case in the emotional reactivity anxious people get caught up in. The automaticity of the fear response is of course adaptive as the involvement of higher cortical pathways is not what is most urgently required in confrontations with the potential damage to one's physical or psychological sense of self. It is the amygdala through its connection to the hypothalamus that instigates the autonomic and extremely rapid action required for the fight-flight-freeze response (Le Doux, 1996). Cortical centres intervene to modulate the response, inhibiting it or promoting it as a reflection of reasoning and meaning-making processes. When having a panic attack for example, sufferers typically respond to the somatic markers of panic with inappropriate and intensifying cortical input (the misinterpretation of their symptoms--'I'm having a heart attack' and catastrophic prediction of their consequences 'I'm going to pass out') which may be initially influenced by complex networks relating to formative early experience (separation anxiety for example as suggested by Day et al, 2004) and the sense of one's identity (I am strong, able, unlucky, weak). The connection between the cognitive and somatic experiences becomes established and entrenched as it is repeated automatically over and over again to the point where sufferers may no longer be aware of the cognitive input but only register the physical phenomena. In such cases the extinction of the malignant concatenation of limbic and cortical mechanisms can clearly be very difficult to achieve without getting the individual to first of all accept and then pay close attention to what is going on within them in order to identify and come to tolerate all the components of their distressing experience.
A defining aspect of Mindfulness is that it trains the mind to deploy attention deliberately. Research indicates that the way we direct our attention is influenced only partly by external stimuli. What we attend to is largely dependent on internal or 'off-line' processes such as for example our immediate concerns. How selective attention is directed has been shown to have an important role in psychological 'disorders' (Harvey et al, 2006). Socially anxious people for example tend to focus their attention inwardly, to signs and thoughts of their perceived inadequacy, thereby failing to notice potential positive external feedback, which would be helpful in making a more accurate assessment of their social competence. Hyper-vigilance in PTSD and other anxiety states, such as agoraphobia and OCD, are other examples of attention processes maintaining 'psychopathology'. Exercising volitional control over one's attention is particularly useful for anybody living in over-stimulating environments (such as for example cities) and even more so for emotionally distressed people who may find this ability especially elusive given that mood and emotional states influence cognitive functioning. The attention training aspect of Mindfulness is therefore invaluable in helping people negotiate their problematic emotional states whatever therapeutic modality they may be working with.
In the course of mindfulness practice individuals are instructed first to focus their attention on a specific object, a region of the body or the breath for example and then to shift it to something else. As they focus on the designated object, functioning as a sort of attentional anchor, they are asked to notice when the mind has wondered off, as it will inevitably do, and then to return the focus to where they had intended it to be in the first place. This act of registering that the mind has wondered entails the adoption of the perspective of observer of one's own thoughts and internal events which facilitates a distancing of the experiencing 'self' from his or her experience, including thoughts. To watch oneself think and recognise one's thoughts as transitory and contingent mental events rather than enduring and accurate reflections of reality is described as meta-cognitive perspective. This is a capacity that is to some degree a prerequisite for any form of therapy as in order to start working on the way they perceive the world, clients need to at least be prepared to accept that this way consists not of objective truths, but of self-generated, contingent and therefore negotiable ideas.
If attention is the equivalent of shining a light on particular aspects of experience, awareness may be described as the capacity to remain alert to what is being illuminated by the beam of light and to what may come in its way and divert it. In awareness we observe the unfolding flow of experience without reacting behaviourally or cognitively. In doing so we allow it to continue flowing uninterrupted by the self-referential, conceptual obstacles we automatically and habitually put in its way. In mindfulness-based therapies as in EPT existence precedes essence. Existence is fluid and insubstantial, forever moving, forever changing. Out of it we create essences, which give us the illusion of stability, continuity and control over the ineluctable random progress towards the demise of our fabricated selves. The sense of self is the most ingrained of our constructions and the one through which most of our experience is filtered. In Mindfulness based therapies as in EPT bringing awareness to the conceptually constructed nature of our identity is conducive to the unlocking of sedimented notions about our selves and the world and therefore to the widening of experiential possibilities. A notion derived from conceptually-based perceiving is that of duality, of a world constituted of independent entities, of separate subjects and objects. As we contact the flowing nature of experience in mindfulness practice we realise that
'nothing, no person, no business, no nation or atom exists in and of itself as an enduring entity, isolated, absolute, independent of everything else. Nothing! Everything emerges out of the complex play of particular causes and conditions that are themselves always changing. This is a tremendous insight into the nature of reality
Conceptual constructions such as the 'self', although useful in many ways, can and do get in the way of the unmediated flow of experiencing, of being, by narrowing down the range of what we let through to consciousness. As therapists involved in the enterprise of guiding our clients through the exploration of their internal landscapes, we must not get bogged down at the conceptual level of processing as we would if we only engaged our clients in talking about their experience. It is important, in pursuing a thorough unearthing of the concealed aspects of a client's way of being in the world that we open up to the additional processing not just of emotions, sensations and behaviour, but to the very process of functioning itself. Through mindfulness practice we become aware of how the endless concatenations of thinking, emoting, sensing and acting create our experience and by becoming aware we are able to exercise a greater degree of choice in how we construct that experience. In this sense mindfulness can therefore be described as 'a transformative process, assisting access to more refined modes of being conscious.' (Mace, 2008:160)
The qualities of this particular kind of receptivity to experience are equanimity and compassion. In a therapeutic context this is an attitude of mind which seems to me essential in applying the husserlian rules of epoche, description and horizontalisation according to which we must pay equal attention to whatever the client presents endeavouring to reduce to a minimum the acts of judging, explaining or prioritising according to our own preconceived parameters.
One view of the existential phenomenological project is that it involves the alignment of the client's worldview, how they conceptualise and make sense of their existence, with their actual current experience of being in the world (Spinelli, 2007). In Mindfulness-based cognitive therapies clients are invited to establish a decentred, non-judgemental, accepting relationship to their experience as it unfolds and in so doing come into full contact with their particular, multifaceted way of being in the world, not just at a conceptual level through reflection and understanding, but, more importantly, experientially. Promoting mindfulness seems therefore in line with the existential-phenomenological therapeutic work. In this article I have pointed out how in fact through the practice of mindfulness in therapy it is possible to avoid the risk of colluding with clients by confining the therapeutic work at a purely cognitive, conceptual level, a pitfall common to all therapies in which the interaction with the client primarily consists of language-based exchanges. This is encapsulated in clients complaining that they know what the problem is, they understand all about it, but that they cannot nevertheless overcome the distressing emotions associated with it.
Mindfulness-based cognitive therapies and EPT share the common aim of the alleviation of suffering and the basic principles concerning the nature of distress and of the sense of self. Both approaches see
distress as deriving from the cognitive appraisal of experience and of the self as a fluid process that we humans reify conceptually for the purpose of adaptive living. By promoting meta-cognitive insight into the aforementioned mediated nature of experience and into the fluid character of self, the practice of mindfulness facilitates the therapeutic process: one's thoughts and beliefs come to be seen as contingent and therefore amenable to change rather than absolute facts that define one's self, others and the world.
Through Mindfulness the main locus of intervention in cognitive therapies moves from the pursuit of change to acceptance, from the cognitive to the experiential and from content to process with people being encouraged to change their relationships to their thoughts, emotions and sensations and to cultivate an attitude of decentred awareness and non-judgemental acceptance of what is, which paradoxically leads to change.
Mindfulness however is not just a technology of change. It is a practice that leads to altering one's internal experience as a whole. The insights it fosters in both patients and therapists are therefore likely to extend from specific aspects of psychological distress to one's beliefs about one's self, others and the world. As a result, Mindfulness promotes a view of the individual as more than a bearer of symptoms. Its therapeutic application has therefore, in much the same way as EPT, the potential to broaden the notion of treatment effectiveness beyond the resolution of specific symptomatology through the deployment of modality-specific interventions, towards the existential question of how to lead a life worth living.
This paper has benefited from long and intense conversations on the subject of CBT and EPT with Jonathan Lee Champion whose paper on the fourth wave CBT also appears in this journal.
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(1) In this respect Adrian Hemmings (2008) distinction between the CBT therapists who are 'technicalists' and those who are 'formulationists' seems apposite. With the former favouring 'a technique-focused style where concern is given to standardised interventions based on experimental and randomised control research methods' (ibid: 44) and the latter valuing the richness and variety of idiosyncratic experience.
(2) Existential therapy is not a homogenous modality either. See Cooper for a full discussion (2003). In this article I broadly follow a model of existential therapy inspired by Spinelli's work.
(3) In this respect it must be noted that in training new CBT therapist a lot of emphasis is placed on the learning of specific strategies designed to bring to light implicit aspects of the client's experience. Such insistence on technique may appear to result in the practice of a mechanistic and restrictive form of therapy. However the assumption here is that more experienced therapist will end up embodying such techniques and strategies and that therefore they will be able to seamlessly make them part of the therapeutic interaction in the true spirit of collaborative empiricism.
(4) In this CBT is amenable to the medical model of mental health currently dominating public service provision, which requires specificity of both presenting problems and treatment interventions. There are however within CBT many critical voices raised against diagnostic classification (Clark, 2008). Important in this respect is the identification of transdiagnostic cognitive processes (Harvey et al, 2006). The psychotherapeutic application of mindfulness to a variety of psychological problems and the research on how its specific components promote change provide impetus for a trans-diagnostic conceptualisation of mental health difficulties.
(5) This is also a fundamental insight in Buddhism: 'We are what we think' the Buddha declared in the Dhammapada Sutra 'All that we are arises with our thoughts. With our thoughts we make the world'
(6) Socratic questions are those that widen the client's perspective and illuminate 'that which the client already knows, but which was never synthesised or was forgotten or was excluded, distorted or discounted by prevailing cognitive biases' (Kennerley, 2007:4). Beck (1979) himself was clear as to the importance of eliciting what the client is thinking rather than drawing one's own conclusions as to what that is likely to be. This is echoed by Padesky's use of guided discovery to test one's hypotheses as therapists of what might be going on for a client (Kennerley, 2007)
(7) In addition it is incorporated as a strategies in other forms of therapeutic interventions such as EMDR (Shapiro, 2001) and Schema Therapy (Young et al, 2003)
(8) In this respect it is important to note that a conceptual framework is important for meditative practice as 'someone who tries to meditate without a conceptual understanding of what he or she is doing is like a blind person trying to find the way in open country' (Kalu Rinpoche, 1986: 113 in Epstein 2007)
(9) Therapists themselves need to practice mindfulness and embrace its principles of empathic acceptance, non-judgemental responsiveness and focused attention before they can share it with their clients. It is therefore likely that the quality of therapist presence and therefore of the therapeutic alliance will be enhanced. See O'Driscoll, (2009) for a review of the literature on this subject
(10) This is also Frederick Perls' 'Paradoxical Theory of Change' which is at the foundation of Gestalt therapy
Marina Claessens is a Chartered Existential Counselling Psychologist working in a NHS crisis team and in private practice in west London. She has studied MBCT at the University of Oxford and is currently on the CBT Post-graduate diploma course at Royal Holloway University, London.
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