Clinical Vignette

Alex (he/him) is a 40-year-old cisgender, straight, Hispanic male who was referred for intensive outpatient psychotherapy twice per week to address substance use, anxiety, and anger management. He is divorced with two young children from whom he receives weekly visitations and his support system includes his mother and children. He recently participated in, and graduated from, residential rehabilitation treatment for substance use and he has been sober for four months. Alex’s presenting problems include episodes of rage and anger, negative self-talk, low self-esteem, hopeless statements, excessive worrying, difficulty relaxing, insomnia, high reactivity (to addictive urges, social interactions), and occupational and social challenges. Although Alex remained sober for the duration of his inpatient treatment, he continues to worry about maintaining his sobriety and alienating his social support. Alex presented to treatment highly motivated for individual therapy and readily explored various ways to address his emotional dysregulation and interpersonal conflict. Alex eagerly completed homework and routinely asked for more work. However, employing self-care coping skills, relaxation tools, and misguided meditation interventions left him feeling frustrated and hopeless about his recovery and mood management. Alex largely utilized mindfulness practices as an avoidance tool. The present vignette highlights the benefit of appropriately pacing treatment with mindfulness as a core intervention.

Key Background

As more and more clinicians are exploring the integration of mindfulness practices in their clinical and research work, it’s important to understand the roots of this ancient practice and its parallels with modern psychotherapy. Buddhist psychology supports a framework that one’s psychological state depends not solely on their circumstances but on how they relate to what comes their way. A component of this theory is that pain is inevitable and with that pain comes suffering. However, it is human nature to add additional layers of psychological suffering by how one engages with their experiences. Alongside Western psychotherapy, mindfulness meditation developed in response to psychological suffering (Fulton, 2013).

One method to address suffering is identifying and acknowledging maladaptive reactivity to stress. Mindfulness has been shown to reduce emotional reactivity by inviting individuals to face challenging (or enticing) experiences with a more open and nonjudgmental mindset (Uusberg et al., 2016). The benefit of this is the increase in likelihood that one will respond consciously and with intentional consideration to overriding the autopilot state. Over time, the conditioned response becomes weakened. Additionally, having the skillset to pause, notice, and make attentive decisions to react versus respond have shown a calming effect on the nervous system (Smith et al., 2019), which directly challenges fight/flight/freeze behaviors. It has also been shown that mindfulness is associated with neuroplasticity (Hanson, 2017; Lardone et al., 2018) and changes in the brain structure, including in the amygdala (responsible for processing fear and threat) and prefrontal cortex (responsible for cognitive control functions). Other meta-analyses have shown moderate reduction in stress and in symptoms of depression, anxiety, and distress (Khoury et al., 2015). Additional reviews show inconsistent findings about the size of treatment effect for reducing stress, anxiety, and depression secondary to physical illnesses or psychological disorders (Baer, 2003; Chiesa & Serretti, 2010). These inconsistencies may be due to various factors such as choice of mindfulness-based protocols, restrictions of specific research designs, and inclusion of a particular group of patients (Khoury et al., 2013).

What Mindfulness Is and Isn’t

Mindfulness is a deceptively simple way of relating to human experiences, yet many individuals have fundamental misconceptions about what it is—particularly from pop culture and mass media. There is also added confusion about the terminology mindfulness and meditation, which oftentimes are used interchangeably. Simply put, meditation is a tool (an intentional practice) used to cultivate mindfulness (a quality of being). You can be mindful without having a meditation practice, but you cannot be in a state of meditation without mindfulness.

Many of the world’s meditation practices fit into three categories: concentration practices, open monitoring, and compassion training. Concentration involves focusing one’s attention on a specific object such as a prayer, mantra, bodily movement (e.g., yoga), or visualized image and being completely absorbed by the focal object while actively excluding everything else from awareness. This type of practice can be beneficial for strengthening focus and grounding the mind especially during times of emotional distress. Open monitoring is nondirective and invites expansion on the present moment as a whole and welcomes each experience (e.g., thought, image, sound, physical sensation, etc.) to flow to the surface of awareness naturally without reactive judgment or pressure to change the experience. It involves intentional focus of everything that arises without exclusion of anything. Lastly, compassion training or loving kindness meditation is a directive practice that cultivates feelings of goodwill, kindness, and compassion toward oneself, others, and humanity.

To better understand what this practice entails, we must first look at what mindfulness is not. Alper (2016) has described the following:

  • Mindfulness is not a relaxation technique or a state

  • Relaxation may be a by-product but it is not the goal

  • Mindfulness is not emptying the mind of all thoughts

  • Mindfulness involves changing our relationship to thinking itself; not abstaining from all thoughts

  • Mindfulness is not a type of contemplative thinking nor is it not thinking

  • Mindfulness does not require a specific posture, position, or practice

Alper further argued that defining mindfulness can be difficult because it is the experience of experiencing itself. How can one logically operationalize an experience that is meant to be felt and sensed? Kabat-Zinn (2003), a leading pioneer of mindfulness in healthcare, has defined mindfulness as “the awareness that emerges through paying attention, on purpose, in the present moment, and non-judgmentally to the unfolding of experience moment by moment” (p. 145). It also involves equanimity, which is mental calmness and composure especially in a difficult situation.

Although many clinicians are familiar with bringing mindfulness meditation as an intervention, less is known about how mindfulness can transcend the clinical space through the clinician’s own practice and within the therapeutic relationship. The following section will further explore practice challenges.

Clinical and Ethical Challenges

Teacher as the Student

Mindfulness is a unique instrument wherein the psychotherapist will greatly benefit from having some sort of foundational mindfulness practice to best understand how to bring it into their clinical work (Segal et al., 2012). Unlike other interventions, most clinicians do not need to experience their own cognitive behavioral therapy to facilitate it—many of these interventions can be conceptualized intellectually and implemented with success. Mindfulness, on the other hand, is best understood experientially, whether informally or formally. Psychiatrist Dan Siegel discussed how mindful awareness training can help establish more secure, empathic therapeutic relationships that foster a combination of presence, attunement, and resonance (Siegel, 2010a). These are the qualities that help our clients feel “seen and heard”—vital ingredients to develop safety and trust for facilitating positive change. Alternatively, there are not enough studies to adequately capture the efficacy of treatment outcomes with a therapist’s varying level of personal mindfulness practice as a factor. Some studies show no correlation between therapists’ level of mindfulness and treatment results (Plummer, 2009; Stratton, 2006). This may be due to varying definitions of mindfulness, specific measures used, and the lack of causal path studies. Although treatment outcomes have generally not been studied experimentally, Pollak et al. (2014) contended that “therapists who practice mindfulness regularly believe it enhances therapeutic effectiveness” (p. 29).

Motivation

One of the clinical challenges when introducing mindfulness to clients as an intervention is explaining what the process may look like. Clinicians ask their clients to put great trust in their techniques and to be the holder of their well-being. Unfortunately, a major tenet of mindfulness involves “non-doing,” which can superficially seem counterintuitive to helping clients attain their treatment goals and outcomes. Mindfulness is best understood as a pragmatic approach and for some, not having a clear boundary of the end goal may reduce the buy-in for this intervention. As in our vignette, Alex presented with apprehension and mistrust when mindfulness was re-introduced in the therapeutic space. He wanted the clinician to tell him exactly what to do, how to do it, and when do to it. He expressed fears about his own ability to make sound decisions and spent a great deal of effort “filling his cup” with self-help books, videos, and excessive self-care exercises to stay sober and get rid of his anger. Upon his initial assessment, it was clear that Alex found creative, albeit futile, ways to avoid any distressing thoughts and feelings that arose.

Mindfulness also requires a level of willingness and commitment for introspection. Clients should have a sense of emotional safety to come head-to-head with whatever their awareness decides to bring up. Some clients may not have the adaptive skills to face distressing emotions quite yet and asking them to “be with” those feelings can elicit more apprehension. Also, some clients may not want to venture away from traditional talk therapy and/or may simply want a quick fix. It is recommended to fully explore the client’s emotional pain and understand what they want or value from treatment (Hayes et al., 1999) before any introduction of a mindfulness practice in therapy. Siegel (2010b) has found it beneficial to psychoeducate clients about brain mechanisms and the stress reactivity cycle as a method to increase the motivation and buy-in of learning this new skill.

Mindfulness as a Secular Practice

An added ethical challenge with broaching the topic of therapeutic mindfulness is if and when it is appropriate to discuss the relationship between mindfulness as a religious practice and mindfulness as a psychotherapeutic intervention. Kabat-Zinn (2003), founder of the Mindfulness Based Stress Reduction (MBSR) program, argued that mindfulness is not Buddhist but the essence of Buddha’s teachings in that the teachings are universal and compatible with science with the focus to end suffering in the here and now. Whether the practice is introduced informally and secularly in therapy, Levin (2019) posited that psychotherapeutic mindfulness clients are not typically informed of the religious origins of the techniques (pp. 591–605), which can violate informed consent obligations. It is recommended to briefly identify the roots of mindfulness but a thorough explanation is not necessary to benefit clients. Furthermore, mindfulness is not unique to only Buddhism—it exists as a concept within many major religions such as Hinduism, Islam, Judaism, and Christianity. The term “contemplative practices” can be analogous to mindfulness practices and it is this author’s guidance that changing the language may be better received for inclusion and sensitivity of a client’s particular religious practice. Contemplative practices can include deep concentration and quieting the mind (e.g., through prayer).

Naming a Feeling as It Is

Mindfulness practices can provide an alternative way of relating to not only experiences but also how one identifies with their feelings. It is not uncommon in psychotherapy and psychopathology to utilize terminology that unintentionally describes an experience as a thing versus a process. This may result in overidentification of the emotion as an internal part of the individual’s identity instead of an external fleeting experience of the moment. Take our vignette for example and how Alex describes his anger and rage: Alex would often make statements such as “I am just a hateful person, I always have been!” He truly believed this to be a part of his identity, which oftentimes elicited shame. We learn later in therapy that many of Alex’s tumultuous social interactions resulted from his anticipation of feeling shame and a need to preemptively strike out first as a protective defense. Mindfulness awareness of distressing emotions can offer an unconventional way to relate to the experience: an understanding that this feeling is in fact temporary and does not constitute the person as a whole. Alper (2016) compared this concept to the experience of a physical itch and comically states you would not say “I am a tingle person” or “I am an itch person” (p. 23). Of course, emotions are more complex and nuanced than a physical itch, but mindfulness may offer a contrasting lens to view and engage with distressing emotions.

Defenses

Another clinical dilemma with applying mindfulness practice is a client’s ability to use it as a maladaptive defense. Sometimes these practices can be used as acts of avoidance especially when there is difficulty tolerating negative feelings (Pollak et al., 2014). Pollak et al. noted that for some individuals, “clinging to concentration” can be utilized unconstructively to avoid painful feelings, which can get in the way of enjoying other present moment experiences (p. 20). Of course, at times this can be a temporary but necessary method to cope with extremely distressing thoughts and feelings and/or potential retraumatization. However, prolonged engagement in focused attention and/or concentration meditation as a means to avoid should be explored further with the client.

Cultural Mindedness

Central to the therapeutic alliance is a therapist’s ability to interact, understand, and communicate effectively and respectfully with people whose cultural backgrounds may differ from their own. Understanding cultural competence does not simply involve learning about other cultures, but it also means understanding one’s own cultural context and seeing themselves as a cultural being (Calkins, 2020). Practicing mindfulness naturally solicits a gentle curiosity to explore. It challenges the clinician to get comfortable with the uncomfortable, including the cultural difference that may arise between clinician and client. Enriching cultural competence involves acknowledgment that all clinicians have a cultural lens. Calkins further encouraged therapists to explore their own values and what they may bring into the room with clients. Guiding mindfulness-based practices into treatment may also be beneficial for vulnerable populations who experience socioeconomic challenges and lack access to quality care (Bergen-Cico& Proulx, 2018). The practice can foster room for acknowledgment of cultural and diversity assumptions. The challenge is to find salient and cross-cultural teaching that is inclusive of each client’s distinctive needs and backgrounds.

Evidenced-Based Assessment and Practice Considerations

There are currently four well established empirically supported treatment programs that involve mindfulness practices: Mindfulness-Based Stress Reduction (MBSR; Kabat-Zinn, 1990), Mindfulness-Based Cognitive Therapy (MCBT; Segal et al., 2002), Dialectical Behavior Therapy (DBT; Linehan, 1993), and Acceptance and Commitment Therapy (ACT; Hayes et al., 1999).

MBSR is an intensive 8-week training program that offers secular mindfulness training, which was originally developed for stress management but has been extended to address depression, anxiety, pain, and other chronic physical health illnesses (Niazi & Niazi, 2011). DBT employs mindfulness as a core skill that assists clients to gain awareness of and learn to accept their emotions. ACT incorporates a combination of acceptance and mindfulness as its core processes to alleviate suffering by increasing psychological flexibility. MCBT, a modified form of CBT, is designed to help clients increase awareness of negative thought patterns that reinforce depression while teaching them how to develop a new relationship with those thoughts.

Cognitive therapy interventions can be adapted with mindfulness practices to help the patient conceptualize negative thinking as a transitory mental event rather than as a part of the self. Teasdale et al. (2002) described this process as metacognitive awareness and they indicated that patients who participate in this form of therapy may reduce depressive relapse. The primary focus of the intervention involves shaping the relationships to negative thoughts instead of changing the belief in thought content. This encourages the patient to disidentify with their negative thoughts, which offers a wider context to understand their experiences.

While employing mindfulness in the therapeutic space, a therapist can maintain fidelity to a specific evidence-based intervention or have flexibility in incorporating aspects of the practice to fit the evolving needs of the client, which can be done implicitly or explicitly.

Becoming a Mindful Therapist

As more clinicians are utilizing mindfulness in their practices, expectations for personal practice will vary greatly. A helpful guideline is that a clinician should, at minimum, have practiced and experienced what they teach (Davis & Hayes, 2011). A benefit to a personal practice is that it can help the clinician “gain confidence in using mindfulness under a variety of circumstances and with different states of mind” (Pollak, 2013, p. 135).

There are ample ways to practice mindfulness personally but the easiest way for many is to start with an informal practice, which requires minimal investment of time. An example adapted from Pollak et al. (2014) may look like:

Concentration Meditation

• As you wait for your next session to start, notice physical sensations for a few moments what it feels like be seated. Simply observe any. Notice the position of your body and external feedback you may experience (e.g., floor on feet, chair supporting back, etc.). Just sit with what you notice for a few moments

• Take a few breaths and pause to observe any physical sensations of the breath. Invite yourself to notice how the breath feels without creating a story about it or a need to change the quality of it. Notice where you feel the breath the most (e.g., nostrils, throat, diaphragm)

• Should thoughts and feelings appear, allow them to arise and pass, bringing your attention back to the physical sensations

This simple exercise can be expanded to other parts of the clinician’s daily life such as when you brush your teeth, take a sip of coffee, or lie down for sleep. As you can see, it does not need much time or effort—it simply requires intention. However, it is also possible and practical to expand upon this and learn a more formal practice. Many are acquainted with the benefits of a consistent mindfulness practice such as positive effects on brain structure and functioning (Lazar et al., 2005) and improving affect regulation (Ramel et al., 2004). However, the bounty of mindfulness is often subtle and gradual. Cultivating mindfulness is a bit like physical exercise and the positive changes can take time to observe. This is where commitment is needed to maintain a practice. Pollak et al. (2014) also suggested that mindfulness is more likely to arise when certain conditions are present: spaciousness, simplicity, single-mindedness, and slowing down.

Spaciousness refers to creating physical space in time to allow for more openness between each activity. An example may look like arriving a few minutes early before your next therapy session to settle in emotionally and physically. Modern day society reinforces grind culture: a tendency to do too much and too often with minimal allotted space in between. When there is zero time made for transitions, it is quite difficult to be as present as possible when we are still wrapped around the lingering effects of the last activity. Giving ourselves the time and space will open up more opportunities for attunement to our clients (and ourselves) the best we can. Simplicity refers to a shift in attitude that involves setting aside any preoccupation with the past and/or worries about the future. It encourages coming back to the here and now. Simplicity can also refer to our physical space—creating an uncluttered office and home will allow for more opportunities to focus on the task at hand. Single-mindedness means focusing on one thing at a time. Outside of your undivided attention during session, you can also extend this condition to other parts of your workday. Focus on completing your progress note and only your progress note. Try not to have a working lunch and instead simply enjoy your lunch without the pressure to multitask. Remember, mindfulness is a gentle practice whenever and wherever you can. No need to adopt rigidity with this. Lastly, Pollak et al. (2014) encouraged slowing down as a necessary way to get out of autopilot mode and mindless doing versus just being. Again, pausing simply means stopping for a few seconds, breathing deeply, and moving on. It does not require any special technique or activity. For those who can benefit from more structure and guidance, the following is a recommendation to reinforce a regular practice.

Eight Ways to Maintain a Mindfulness Practice (Pollak et al.,  2014 , pp. 33–34)

1. Make it a habit – make meditation a part of your daily routine. Decide which time of day works best for you and allot a few moments to practice. First thing in the morning or sometime in the evening are good choices

2. Not too long or too short – choose a length of time for formal practice that’s long enough to allow the mind to begin to settle but not so long that you won’t commit to the practice. For most people, somewhere between 15–45 min a day is about right. But even just 5–10 min is great if that works for you

3. Create a sacred space – create an intentional space in your home to practice. It does not have to be fancy, it just needs to be comfortably accessible. You can even bring in items that will help with your intention (e.g., favorite pillow to sit on)

4. Find your seat – if your practice involves sitting, as it does for many, be sure to find a position that allows you to be comfortably upright and supported. The right posture encourages wakefulness and adequate flow of the breath. Try experimenting with sitting on a chair, on a cushion, or on the floor

5. Seek other forms of support – get guidance from a qualified meditation teacher or support group either in-person or through books/audio/virtual. Sitting together with a friend can also help sustain and enliven your practice

6. Suspend judgment – having unreasonable expectations and judging yourself against them can lead to frustration. Remember, the “end goal” isn’t so much as a goal but rather about coming back again and again to where you already are

7. Be gentle but persistent – meditation requires effort but too much effort can be counterproductive. Adopt a gentle approach and allow yourself to find a middle ground for a realistic practice. Good enough is good enough

8. Remember your intention – Why did you start a practice? To gain a peace of mind? To be more present with yourself, partner, friends, and clients? This reminder can be a powerful source to keep you going

Developing our own mindfulness practice can be highly beneficial but not without road bumps, as with learning any new skill. The benefits of mindfulness are cumulative, and patience is required to start noticing the benefits. Studies have shown measurable changes in brain functioning in those who practice consistently for 8–10 weeks (Pollak et al., 2014). It is this author’s recommendation to not let this timeline discourage you and to be kind to your own practice.

The Therapy Relationship

There is no doubt in the clinical world that many factors attribute to a client’s success or failure. Norcross and Lambert (2011) presupposed the following factors for treatment outcome: “the patient, treatment method, the psychotherapist, the context, and the relationship between the therapist and the patient” (p. 2). Their research concluded that the therapy relationship accounts for why clients improve or fail to improve as much as the specific intervention method. As mentioned earlier, there has been limited evidence establishing the link between a therapist’s mindfulness and clinical outcomes due to a lack of qualitative studies. However, Fulton (2013) argued that it’s natural to infer “that the influence of mindfulness of the therapist is consistent with the qualities underlying a successful treatment relationship” (p. 62). He further states, for example, “if mindfulness cultivates empathy, and empathy is associated with an effective treatment relationship, it seems plausible that a therapist’s mindfulness would positively influence outcomes” (p. 62). Fulton’s research highlighted the following elements from a clinician’s mindfulness practice as having a positive impact on the therapeutic relationship: cultivation of attention, compassion and empathy, therapeutic presence, self-attunement, openness and acceptance, boarder perspective on suffering, and nonattachment.

For the sake of brevity, only two qualities will be further explored as they prominently relate to our vignette: cultivating attention and compassion. For clinical practitioners, one can assume they have adequate attentional skills to pick up on their client’s subtleties and the skillset to exercise compassion. But can these skills be further cultivated outside of the clinician’s personal traits? Morgon et al. (2014) wrote that both focused attention and open monitoring can be practiced at home by the clinician or during psychotherapy and can provide the foundation to support clients. Focused attention is the constant returning to awareness again and again while open monitoring is the ability to calmly notice whatever arises in the field of our perception. Practicing attentional skills can help pull clinicians back to the present moment and avoid getting lost in the perspective or theory of their work.

Why is it necessary to talk about compassion training? Compassion deals with emotional suffering, which is essential to psychotherapy and is why clients seek help in the first place. It is possible that compassion be brought into therapy by teaching specific practices to clients and/or by clinicians learning techniques themselves (Germer, 2009; Siegel, 2010b). By doing so, clinicians can aim to deepen the therapeutic relationship. The following are example exercises for the clinicians:

Attention/Concentration Meditation Exercise (Germer et al.,  2013 , pp. 82–83)

• Find a comfortable posture, close your eyes, and allow your body to be supported by the chair

• Take two or three slow, deep breaths, relaxing with the exhalation. With each exhalation, allow the body to become heavier and relaxing more fully

• Allow the breath to find its natural, easy rhythm. Enjoy the relaxed simplicity of sitting and breathing

• Where do you notice the flow of sensations of the breath most vividly – nostrils, throat, chest, or diaphragm? Allow the attention to alight there easily

• Whenever your attention wanders, and you notice that it has wandered, first reestablished the relaxed breath, then return your attention to the flowing sensations of the breath where they are strongest

• Allow yourself a few more breaths before slowly opening the eyes

Compassion Greeting Exercise (Germer et al.,  2013 , p. 93)

• Before you open the door for your next patient (or turn on the camera), take a moment to feel the rising and falling of your breath

• Now visualize the person behind the door, a human being who is suffering, who was once a child, who has hopes and dreams just as you do, and who has tried to be happy and only partially succeeded, who feels vulnerable and afraid much of the time, and who is coming to you believing that you can relieve his or her suffering

• Now open the door and say “hello.”

The following showcases how the clinician utilized attention and compassion mindfulness with the vignette:

Alex typically started session with a frenzied energy to recap his week’s happenings and “dive right into therapy” with his volume usually loud and speech fast. After several weeks of this energy, the clinician noticed apprehension before seeing Alex as the space felt overstimulating and chaotic. However, the clinician engaged in a simple strategy to calm the energy. The clinician would take conscious breaths at the beginning of therapy and by doing so the clinician was able to attune to the veiled pain behind Alex’s behaviors instead of focusing on their own frustration. After the third session, the clinician invited Alex to take a few mindful breaths together before session started. Unsurprisingly, Alex refused and asked why would they waste time doing such an unproductive exercise when there was so much territory to cover? The clinician validated his concerns and asked if he was tired and exhausted. Alex was caught off guard and after a moment of thought his bodily posture immediately slackened as if he just received permission to relax. The clinician explained to Alex that his external energy may reflect his internal suffering and that taking a moment to pause and breathe was permissible. This simple practice also assured the clinician to stay grounded and attuned to the client instead of focusing on ways to alleviate or fix the discomfort in the room.

Client-Centered Practice

A gentle introduction to mindfulness may involve reframing the practice as an “experiment” and should be seen as a collaboration between therapist and client versus the therapist doing something to the client. Paying attention to the language used when introducing the practice is also important. Some individuals may have a negative stereotype about the word mindfulness, associating it with New Age philosophy. Carmody et al. (2009) suggested presenting the practice as attention training may be more palatable to some clients.

As with any intervention introduced in the clinical space, Pollak (2013) reinforced the importance of offering modifications to make practice accessible to different clients and situations. It is this author’s recommendation to be sensitive and mindful to the unique presentation of clients from non-dominant cultures and/or marginalized backgrounds. It is vital to remain relevant, engaging, and culturally responsive. Many practitioners introduce mindfulness with breathing exercises, but clients with a history of trauma, anxiety, or respiratory illnesses may not feel comfortable with the practice of following the breath. Another example may involve asking the client to close their eyes. Again, it is presumptive to think that all clients feel safe with their eyes closed during an exercise. Different individuals often prefer meditations that emphasize auditory, kinesthetic, linguistic, or visual objects of attention (Pollak, 2013). An individual’s learning process and personality style may also contribute to receptivity to a particular meditation practice. Pollak further suggested “rather than seeing a preference for one practice over another as resistance, therapists can be sensitive to and understanding of individual preferences” (p. 137).

A gentle introduction to the world of mindfulness meditation may include a concentration exercise that can be done in just 3–5 min with clients. This client-focused practice cultivates the repetitive nature of coming back to the present moment again and again in a soft manner.

Just Listening Exercise (Pollak,  2013 , p. 140)

• Start by sitting comfortably, finding a relaxed posture that you can hold for a few minutes. Eyes can be open or gently closed. As you settle into the chair, see if you can get in touch with your essential dignity

• Let yourself be in the room, feel the chair you are sitting on, and allow yourself to listen to the sounds around you. Don’t worry about naming or judging them, just listen

• Let yourself listen with your entire being. Open to sounds in front of you, behind you, above you and below you. No need to create a story about them – let them come to you. Just notice the sounds

• Allow the sounds to arise and pass away. No need to grasp – let them come and let them go. If your mind wanders, don’t worry, just return to the sounds in the present moment

The next exercise promotes open exploration of all thoughts, feelings, and sensations with the practice of non-attachment or criticism of the content. This practice is especially helpful for clients to begin recognizing the negative narrative associated with painful thoughts, feelings, and sensations and allows for a natural observation and understanding that this too shall pass.

Leaves on a Stream Exercise (Adapted from Acceptance and Commitment Therapy)

• Sit in a comfortable yet upright position on the chair or floor, let your eyes gently close or keep them open but soften the gaze to a fixed point a few feet in front of you

• Take a couple of gentle breaths in, and out. Notice the sound and feel of your own breath as you breathe in, and out

• Now imagine you are looking at the bank of a gently flowing stream. Imagine feeling the ground beneath you, the sounds of the water flowing past, and the way the stream looks as you watch with open curiosity

• Imagine there are leaves from the trees, of all shapes, sizes, and colors, floating past on the stream and you’re simply watching. At times you may watch a particular leaf and follow it all the way down the stream. Other times, you may simply notice a leaf and then move on to another leaf

• Start to become aware of your thoughts, feelings, or sensations and imagine placing each one on a leaf and letting it float down the stream

• Do this for all thoughts, feelings, or sensations that arise in your awareness, regardless of whether it is a positive, negative, pleasant, painful, or a neutral experience

• Allow the stream and the leaves to float at their own rate. Notice any urges to speed up or slow down the stream or a pull to stay with a leaf longer than others. If a leaf gets stuck, just notice it being around a bit longer. Eventually, that leaf will also move along

• You are simply observing each experience and placing it on a leaf on the stream. It’s normal to lose track of this exercise but just gently and kindly bring yourself back if you notice your mind wandering off

• Finally, allow the image of the stream to dissolve and slowly bring your awareness back into your space. Take a few breaths if your body calls for it. Gently open your eyes or focus your attention back into the room

Any of the mindfulness exercises mentioned earlier in this article can be adapted to your client’s direct practice. As for our case vignette, after several months of mindfulness practice during session and on his own, a compassion exercise was introduced to Alex and was focused on noticing and addressing his anger and addictive urges. Brach (2019), meditation teacher and psychologist, adapted RAIN as an easy-to-remember tool for bringing mindfulness and compassion to emotional difficulty. The following exercise is an extension of attention and open-awareness meditation with the added focus of bringing kindness and support to painful emotions.

RAIN (A Practice of Radical Compassion); Adapted From Brach ( 2019 )

• Recognize what is going on – acknowledge the thoughts, feelings, and behaviors that are affecting you

• Allow the experience to be there, just as is – allow what you notice to simply be there without trying to fix or avoid it. This may look like saying yes or it’s ok for this sensation to be here right now. Allowing creates a pause for space to distance yourself from the sensation

• Investigate with interest and care – have open curiosity to explore. Ask yourself: what’s calling for my attention right now, how am I experiencing this in my body? Try to step away from conceptualizing what you notice and instead bring your attention to the felt-sense in the body

• Note what is happening and Nurture with self-compassion – Notice the experience in your body as you follow it. Use short phrases to describe what is happening in the body: restlessness in body, clenching, rising sensation. Also, by recognizing the moments of suffering, try to sense what the wounded or frightened place inside you most needs. Does it need reassurance, forgiveness, companionship, love? Bring kindness and comfort to what you are sensing. Statements of support may look like I’m sorry, I’m listening, It’s not your fault

Brewer (2013) stated RAIN can offer the individual to “learn to ride the waves of craving by surfing them” (p. 235). This was particularly impactful for Alex in our vignette to come face to face with his addictive urges. He first had to recognize the wanting or craving, relax into it, allow or accept the wave as is (e.g., stating to himself ok here we go, I am allowing this to be here now), and finally notice the craving in his body (i.e., describing the physical sensations in his body). Over time with practice during session and on his own, Alex noticed his ability to incrementally tolerate cravings and associated distressing feelings.

Mindfulness training can teach clients that “instead of running away from unpleasantness by engaging in an addictive behavior, one can learn to accept what is happening right now” and explore those feelings in their bodies (Brewer, 2013, pp. 231–232). This practice helped Alex to learn that cravings are naturally impermanent and gave him the amplitude to utilize adaptive coping tools. With practice, he gained more confidence in his self-efficacy to not only tolerate the cravings but to also make behavioral choices to maintain sobriety. Alternatively, this also challenged Alex to reduce avoidance of addictive cues and open into those feelings and sensations. Research shows that craving is viewed as a major determinant of relapse in persons with substance use disorders (Serre et al., 2013). Mindfulness may offer an alternative method of treatment of avoiding triggering cues or substitutive behaviors by leaning into exploration of the addictive cues. Over time, this can aim to dampen the addictive loop and disrupt the associated learning that is oftentimes reinforced with each feeding of a craving (Brewer, 2013). Mindfulness can be a middle ground between attachment to pleasure and aversion to pain with more opportunities to manage the dysregulation underlying addiction (Garland & Howard, 2018).

Conclusions and Lessons Learned Relating to the Vignette

Clinicians are encouraged to open the practice of mindfulness not only as a clinical tool to treat psychological ailments but also to deepen the richness of the therapeutic relationship and foster the clinician’s own self-care. It is not uncommon for practitioners to get lost in the intervention or in the driven need to help/fix the presenting problem at the earliest onset. Alex, from our vignette, approached therapy with a much-needed intention to do something about his suffering and to do it quickly. Mindfulness practices provided Alex the opportunity to slow down, observe, and nurture his emotional wounds while increasing his awareness of addictive and avoidance behaviors. This bolstered him to respond thoughtfully instead of reactively. The mindful presence also fostered the clinician’s attunement to Alex’s distress, alongside moments of growth, while employing other supportive interventions.

Key Clinical Considerations

  • Mindfulness practices can be incorporated into personal practice for the therapist, in the therapeutic relationship, and through the client’s direct practice by simple meditations on a day-to-day basis. Mindfulness meditation does not require extensive training and/or conceptualization for it to be impactful in clinical practice.

  • Mindfulness meditation largely involves three main types of practices: concentration, open monitoring, and compassion—and any form of meditation can be used in conjunction with other evidence-based interventions.

  • Individual preferences for certain types of meditations may not necessarily mean resistance to the intervention itself. It behooves the clinician to explore alternative styles of meditation practices to best fit the diverse needs and presentation of each client.