03.01 Differentiation

Murray Bowen, the founder of Natural (or Family) Systems Theory, believed that problems occur  in families due to fused relationships. A fused relationship is a relationship in which two (or more) members of a family become so emotionally entangled with each other that it is difficult, if not impossible, to tell where the thoughts and feelings of one person end and the thoughts and feelings of the other person begin. In a fused relationship, a person feels ‘smothered’ by the needs and desires of another person. In such a relationship, one person is absorbing the anxiety and stress for the entire relationship. He or she is held responsible for the success or failure of the relationship. Such a person has taken on the responsibility for the emotional wellbeing of the other person(s) in the family.

Such a state can be emotionally and cognitively debilitating to the persons enmeshed in the dysfunctional relationship.

At the other end of the spectrum lies differentiation.

One definition of differentiation could be: “The ability to separate thinking and feeling about a given relationship or situation.”

When a person lacks the ability to separate their emotions from their thoughts, that person is said to be undifferentiated. Being undifferentiated means being flooded with feelings and powerful emotions. Such a person has a great deal of difficulty thinking rationally. Additionally, such people may feel that they are responsible for other people’s feelings, and that other people are responsible for their feelings. They lack the ability to tell where their feelings end and other people’s feelings begin.

The process of differentiation involves learning to free yourself from emotional dependence and codependence on your family and/or romantic relationships. Differentiation involves taking responsibility for your own emotional well-being, and allowing others to be responsible for their own emotional well-being.

A fully differentiated person can remain emotionally attached to the family without feeling responsible for the feelings of other family members.

Mindful Awareness

One of the skills we develop in the practice of mindfulness is the skill of acceptance. Acceptance allows us to experience emotions without feeling obligated to react to them. This is done by noting the emotion, and then letting go of the thought processes that the emotion generates. By letting go of these negative thought processes, we come to accept other people for who they are, without feeling the need to try to manipulate the situation or to take responsibility for the emotional outcome of our interactions with other people.

An undifferentiated person can benefit from mindfulness by learning to accept the flood of emotions that blocks rational thought. The goal of acceptance in differentiation isn’t to become a totally rational person, devoid of emotion.

Instead, the goal is to practice wise mind. Wise mind is the balance of emotional mind and rational mind, in perfect harmony.

As mindful awareness increases, acceptance of others increases as well. As acceptance of others increases, differentiation also increases.

Cognitive Behavior Therapy and Differentiation

The primary goal of Cognitive Behavior Therapy (CBT) is to modify maladaptive thought processes in order that we may obtain more positive consequences. CBT is a type of metacognition, or “thinking about thinking.” Therapists and counselors who use CBT are helping their patients to focus on their belief systems and to examine the thoughts and feelings that lead to consequences they may not want. By changing those thought processes, the consequences of those belief systems should change.

A person who is not differentiated generally believes that he/she is responsible for the happiness of others, and that others should be responsible for his/her happiness as well. This idea usually manifests itself in the form of, “If _____ would just behave the way I want him to, then I’d be happy,” or, “She expects me to make her happy by doing _____ .”

As mindful awareness increases, practitioners of mindfulness come to realize that each individual is responsible for his or her own happiness. By being present in the moment, a practitioner of mindfulness comes to realize that “it is what it is.” In other words, by accepting that we are responsible for our own emotional well-being, and others are responsible for theirs, we learn to become fully differentiated.

Case Study: Harry and Sally

 Harry and Sally, a married couple in their mid-thirties, were having difficulties after ten years of marriage. After the birth of their second child, Harry felt that Sally had become more emotionally distant and that she had turned into a complete stranger. Sally felt that Harry was smothering her by making far too many demands on her time and attentions. Harry felt that he would be much happier with the relationship if Sally would pay more attention to his needs, and less attention to the needs of the children. Sally felt that she would be much happier in the marriage if Harry would just, “Back off and let me have some space.”

As Sally and Harry began to practice mindfulness skills, their mindful awareness grew, as did their ability to achieve radical acceptance.

Eventually Harry was able to see that instead of relying on Sally to, “Make me happy,” he could be responsible for his own happiness. Sally came to realize the same. As Harry learned to take responsibility for his own happiness, his demands on Sally’s attention decreased. As these demands decreased, Sally felt less pressured to try to ‘make’ Harry happy. As these pressures and demands on Sally’s time decreased, she became more willing to spend time with Harry, because, “I don’t feel as if he’s smothering me anymore. He’s learned to be happy with himself, and I don’t feel as if I have to work to make him happy.”

03.02 Acceptance and Commitment Therapy (ACT)

According to Bach and Hayes (2002): “Acceptance and Commitment Therapy (ACT) is based on the view that many maladaptive behaviors are produced by unhealthy attempts to avoid or suppress thoughts, feelings, or bodily sensations (Hayes, Wilson, Gifford, Follette & Strosahl, 1996). Among other components, patients are taught (a) to identify and abandon internally oriented control strategies, (b) to accept the presence of difficult thoughts or feelings, (c) to learn to “just notice” the occurrence of these private experiences, without struggling with them, arguing with them, or taking them to be literally true, and (d) to focus on overt behaviors that produce valued outcomes.”

ACT has a wide variety of clinical applications. Research has demonstrated that it is especially useful in helping to reduce negative behaviors and their impact by teaching practitioners to accept troubling and stressful thoughts and emotions instead of fighting them. Acceptance of these thoughts and emotions then keeps them from interfering with desired positive behaviors (Bond & Bunce, 2000). ACT has also been used to increase acceptance (tolerance) of chronic pain, even if the pain itself is not reduced (Hayes, Bissett, et al., 1999).

ACT: A Contextual Approach

Steven C. Hayes, of the University of Nevada, Reno, is the founder of ACT. It is a contextual approach, meaning that it is based on the four factors of Contextual Therapy. These factors are: 

  1. facts pertinent to the client (medical history, genetic factors, physical health, employment, etc.);
  2. individual psychology (the patient’s psychodynamic constitution);
  3. Systemic interactions (how the patient interacts with the family system, and other factors pertaining to the biopsychosocial context in which the patient lives), and
  4. Relational ethics (the unwritten and often unspoken rules about how the patient interacts with her family, and how the family interacts with her).

The “context” of contextual approaches refers to all of the factors that make up a person’s personal narrative; her life story. Contextual therapies believe that all behavior, even maladaptive behavior, is purposeful when examined in the patient’s context. From this viewpoint, a therapist asks, “What is the function of the dysfunction?” In other words, what contextual processes are serving to maintain the problematic interactions?

The basic premise behind ACT is that a certain amount of suffering in the form of anxiety, stress, depression and other troublesome thoughts and behaviors, is inevitable. ACT seeks to minimize the negative impact of negative thoughts and feelings by teaching practitioners how to accept them. This is often expressed with the acronym ACT:

Accept the effects of life’s hardships,
Choose directional values, and
Take action.

Relational Frame Theory (RFT)

Another key element of ACT is relational frame theory (RFT). One of the aspects of this approach is the theory that many psychopathologies are the result of attempts to avoid negative internal thoughts, feelings and behaviors. RFT examines how we use our language and vocabulary to remain trapped in these cycles of approach/avoidance. By examining the language we use to contextualize such situations, we are able to restructure these internal dialogues so that they have more positive outcomes. We do so by accepting that negative thoughts and feelings are a normal part of existence.

Core Processes of ACT

Hayes (2005) describes six core processes of ACT: 1. acceptance, 2. cognitive defusion, 3.being present, 4. self as context, 5. valuing, and 6. committed action. Wilson et al (1996) provides a method for using these six core processes in therapeutic interventions. An overview of this process would be:

1. Acceptance: This is the “A” portion of ACT. The first step in acceptance in ACT is to assess the patient’s patterns of avoidant behavior. These behaviors are then re-contextualized to patterns of acceptance.

2. Cognitive Defusion: If the therapeutic goal is to reduce anxiety, and effort is a cause of anxiety, then “trying hard” to minimize anxiety only generates even more anxiety. By examining this paradox in context, ACT defuses it by allowing the patient to recognize that thoughts and feelings are just processes of the mind. Thoughts and feelings are not facts; they are merely thoughts and feelings.

3. Being Present: attempting to avoid internal negative processes is akin to trying to run away from your own shadow. By turning to face these processes instead, patients learn to accept them without having to engage in the downward spiral they tend to create. This is done by avoiding the tendency to assume that thoughts and feelings are facts, but instead asking yourself, “Is acting on this thought helpful or effective?”

4. Self as Context: Here the patient learns to step back from “self in content,” and to engage “self in context.” This idea is similar to the process of externalization in Narrative Therapy. The patient is taught to engage the objective internal observer (True Self) to recognize that thoughts and feelings are content separate from the context of the True Self.

5. Valuing: ACT defines this as, “Choosing a direction and establishing willingness (acceptance)” to focus on process instead of content. This means learning to avoid the temptation to confuse values with goals. ACT enhances a client’s motivation to work towards values by engaging in the process of living, rather than becoming stuck in focusing on the content of negative thoughts and emotions.

6. Committed Action: This is the “C” portion of ACT. In the final stages of therapy, the patient makes a commitment to stop trying to avoid the past and to move forward by continuing to seek opportunities for further empowerment.

ACT Techniques and Protocols

Techniques in ACT include the use of metaphors, paradoxes, and experiential activities. Gifford, Hayes, and Stroshal (2010) define several protocols for designing these techniques. Some of these include:

1. Creative hopelessness: In this protocol, patients are asked to examine things that they have tried to make better, and to see which of these techniques have actually worked. For those that have not worked, they are asked to “make space” for something else to happen. This protocol encourages a 180-degree turn from behaviors that have not worked in the past. In short, “If what you’re doing isn’t working, try something else.”

2. Acceptance techniques: Patients are asked to reduce their motivation to engage in avoidance behaviors by unhooking their thoughts and feelings from their actions. This acceptance strategy allows them to realize that they don’t necessarily have to act on thoughts and feelings just because they are experiencing them.

3. Deliteralization (cognitive defusion): In this protocol, patients learn to observe the process without getting caught up in the outcome. By learning that thoughts are simply processes, not outcomes, the content of maladaptive thoughts can be deliteralized or defused so that they don’t have to become outcomes.

4. Valuing: In this protocol, patients are asked to focus on the things that give their lives meaning. By making choices on values, the client develops a clearer sense of self. This helps to draw the distinction between values and goals.

5. Self as context: This is a shift from content to context. This protocol allows the client to use her values to define an identity that is separate from the content of her experience. It is designed to help the client realize her identity is not the sum of the contents of her experience.

ACT Resources

There are several sites that contain resources on Acceptance and Commitment Therapy. You may wish to bookmark these for future reference:

ACT for Anxiety Disorders

Acceptance and Mindfulness — New Harbinger

Acceptance and Commitment Therapy

Center for Mindfulness in Medicine at UMASS Boston

Relational Frame Theory

Mindfulness from a Buddhist Perspective––Pema Chödrön

03.03 Dialectical Behavior Therapy (DBT)

Dialectical Behavior Therapy (DBT) was created by Marsha Linehan, PhD as a method of treating Borderline Personality Disorder. Prior to DBT, the treatment of Borderline Personality Disorder (BPD) met with limited success. DBT, a type of Cognitive Behavioral Therapy (CBT), has been demonstrated to be an effective treatment not only for BPD, but for many other dysfunctions as well.

DBT is founded on the principle of the Hegelian Dialectic. Georg Wilhelm Friedrich Hegel’s concept of the dialectic is usually described as: thesis/antithesis/synthesis, wherein the thesis is the theory or idea in question, the antithesis is the idea’s polar opposite, and synthesis is a fusion of thesis and antithesis. DBT examines the dialectics behind maladaptive thought patterns and attempts to achieve a synthesis in order to restore balance to the psyche. For example, people with BPD often engage in splitting, in which they see a person either as all bad or all good. In this case, “all good” would be the thesis, and “all bad” would be the antithesis. A synthesis of these two ideas would be the realization that sometimes bad people can do good things, and sometimes good people can do bad things. DBT makes use of the dialectic to challenge maladaptive patterns of behavior.

Another example, and one of the major dialectics used in DBT, is the Acceptance vs. Change dialectic. In this dialectic, the patient learns to accept her flaws and imperfections, and to come to the realization that it is okay not to be “perfect,” while at the same time realizing that making changes in destructive coping patterns could lead to a happier, more productive life.

DBT grew out of Linehan’s work with BPD patients in the 1970s. She had this to say about the beginnings of the model: “People who meet the criteria for BPD almost always hate themselves,  so I figured I needed to accept them myself, and then teach them how to accept themselves. If you don’t accept yourself as you are, you can’t change. It’s a paradox, but true.”

Fundamental DBT Concepts

One of the fundamental assumptions of DBT is that patients are doing the best they can. Adler (1957) said that, “All behavior is purposeful when you understand the context.” According to the tenets of DBT, patients behave the way they do because at some point in time those behaviors yielded beneficial results. Over time, these patterns of behavior may not remain as successful, but patients become stuck in those patterns because they don’t know how to change.

Another assumption of DBT is that patients are motivated and willing to change. When a patient becomes stuck in a pattern of behavior, she may not be able to see a way out. This does not mean that she doesn’t want to change. She knows her impulsive and maladaptive patterns may be leading her to consequences she doesn’t want to experience. In short, BPD patients often have a strong motivation and commitment to change.

The third and final fundamental assumption of DBT is that radical acceptance is essential to recovery. The paradox at the heart of DBT is that before you can change, you must first accept yourself exactly the way you are. This means examining yourself non-judgmentally, without blaming, shaming or guilt. By coming to the realization that they were doing the best they knew how in a given situation, patients learn to accept that they are human, and they are entitled to make mistakes. This acceptance of self then frees them up emotionally and mentally and allows them to move forward towards change.

DBT and Emotional Regulation

A common problem in most mental dysfunctions and disorders is the tendency to become overwhelmed by powerful emotions. Such emotional flooding tends to disengage the mind’s capacity for rational thought. DBT uses mindfulness to create a space between overpowering emotions and the patient. By learning to step back from these emotions, patients come to see them as processes of the mind, and not necessarily as components of their identity. It’s not, “I’m a bad person because I’m having bad feelings.” DBT uses Mindfulness to teach patients that, “I’m a good person who occasionally has negative thoughts and feelings, and that’s okay.”

DBT: The Process

DBT is a long-term therapeutic intervention. Maladaptive behavior patterns can often be difficult to change, especially in the case of Borderline Personality Disorder. Because of this, DBT interventions routinely last two years or longer.

DBT patients have two sessions per week. One of these sessions is a skills training session (often in group format) and the other is an individual session with a DBT therapist. DBT therapists also offer coaching calls by telephone as a method of crisis management. When using such coaching calls it is important that the patient understand and agree to the limits of confidentiality regarding the sharing of clinical information by telephone.

Skills Training in DBT is comprised of four modules: distress tolerance, core mindfulness, emotional regulation, and interpersonal effectiveness.

Core mindfulness is the cornerstone of the other three modules. By learning mindfulness skills, patients learn to live in the moment. Since most anxiety and depression is rooted in thoughts and feelings about past or future events, mindfulness skills help patients overcome such anxieties by focusing on the “now” of existence. Mindfulness skills also help patients with Borderline Personality Disorder to overcome the tendency to make assumptions about situations, and to simply see what is there.

Distress tolerance works by teaching patients to find ways to distract themselves from troubling thought and feeling patterns that are self-destructive. Instead of engaging in cutting behavior, for example, a DBT student might do something nice for someone they’re angry with. Patients are taught to know their bodies, and how their bodies react to certain emotional states. By becoming familiar with the physiological changes their bodies go through as a precursor to a stressful state, patients gain more space and time in which to engage in distress tolerance skills. By examining their own beliefs and assumptions about the stressful situations, the patients also learn to create less maladaptive responses to such situations.

The emotional regulation module focuses on reducing and minimizing the intensity of overwhelming emotional cycles of response. Patients with Borderline Personality Disorder are by definition highly emotional people. In order to fit in with less emotionally-sensitive people, many people with Borderline Personality Disorder have learned to suppress stronger emotions. Over time, this suppression leads them to have difficulty in identifying cues that indicate the onset of a strong emotional cycle. In many cases, the tendency to suppress emotions can lead to the eventual inability to define subtle nuances of emotion. Most, if not all, emotions tend to become identified with one emotional state. For example, sadness, fear, and guilt may all be expressed as anger. The emotional regulation module focuses on learning to identify emotions so that their negative impact may be successfully minimized.

People with Borderline Personality Disorder often feel socially isolated simply because of their dysfunctional patterns of interaction. They literally don’t know how to behave in certain social situations. The interpersonal effectiveness module helps them to learn the skills necessary to navigate day-to-day social interactions. By learning to examine and challenge their negative assumptions about social situations, patients learn more positive resolutions to those situations. As their skills in social situations increase, their fear of abandonment diminishes.

Other Uses of DBT

Although DBT was created to treat patients with Borderline Personality Disorder, it has also been used to successfully treat many other dysfunctions. DBT has been demonstrated to be particularly effective with addiction issues and anxiety disorders. There are, however, some cases in which DBT might not be effective. Since it is a long-term treatment program, requiring two sessions per week, it is often quite expensive. People with limited financial resources might not be able to have access to such services. DBT also requires that the patient have a high motivation and commitment to change. It is an intense form of intervention, requiring a lot of hard work. If a patient is not committed to the process, DBT might not be the most effective form of therapy.

03.04 Mindfulness-Based Cognitive Therapy (MBCT)

Origins of MBCT

Jon Kabat-Zinn developed Mindfulness-Based Stress Reduction (MBSR) as an eight-week program for people with stress-related health issues such as high blood pressure, heart disease, and chronic pain. The success of Kabat-Zinn’s program let Zindel Segal, Mark Williams, and John Teasdale to create Mindfulness-Based Cognitive Therapy (MBCT) as a means of preventing relapse for their patients who had been treated for chronic depression issues.

Segal, Williams and Teasdale released their book, Mindfulness-Based Cognitive Therapy for Depression: A New Approach to Preventing Relapse in 2002.This work is the definitive text on MBCT.

What is MBCT?

Segal, Williams and Teasdale adapted Kabat-Zinn’s MBSR program for specific use with people suffering from chronic depression. MBCT is the result of this modification. MBCT helps practitioners understand the nature of depression. Students of MBCT learn the specific states and conditions that leave them vulnerable to downward spirals of depression. MBCT also uses radical acceptance strategies to help patients overcome feelings of inadequacy that lead to cycles of depression. Research into the effectiveness of MBCT in preventing relapse (a return to depressive symptoms) demonstrates that the techniques of MBCT can reduce rates of depressive relapse by as much as 50% (Ma and Teasdale, 2004; Teasdale et al, 2000).

MBCT and Depression

 The most common treatment for depression is antidepressants. While antidepressants can alleviate the symptoms of depression, they do nothing to treat the root causes of the depressive state, and when the patient stops taking the medication, the symptoms can return. Depression is often described as a “bottomless pit” or a “black hole.” Once a person has entered this state, it is very difficult to climb out of the pit of depression.

As the symptoms of depression worsen, hopelessness increases. Physical ailments often accompany the depression. These physical maladies are generally caused by the depression and not by any physical illness. If allowed to progress far enough, this sense of hopelessness and helplessness can lead to suicidal thoughts.

A person who has experienced one major depressive episode has about a 50% chance of having another. After a second episode, the risk of having a third rises to somewhere between 80% and 90% (Teasdale et al, 2000).

One theory of problem development with depression says that negative thinking leads to negative moods. Research tends to support this theory. The reverse is also true: negative mood leads to negative thinking. When a person starts to consider himself a failure, or when hope seems to have disappeared, both negative thoughts and negative moods reappear.

This pattern of brooding over negative thoughts is called rumination. When rumination begins, a return to depression is almost inevitable. Rumination occurs because the depression sufferer is trying to seek a solution; he is looking for a way out of the depression cycle. Paradoxically, rumination only serves to intensify feelings of hopelessness and helplessness, which in turn reinforce the depression, making things worse instead of better.

MBCT helps to defuse this downward spiral of depression by allowing practitioners to identify these negative cycles of thought and mood, and to slow or stop the process of rumination before it spirals out of control.

How Does MBCT Work?

As noted above, depression sufferers often describe the experience as being at the bottom of a well or a pit. In such a situation, a sort of mental tunnel vision sets in. MBCT draws on mindfulness skills to help practitioners identify the signals of such negative interactional patterns early, before they have a chance to develop into a full-blown depression. Mindfulness allows the patient to see that negative thought and mood cycles are simply processes. They do not have to choose to participate in those cycles if they do not wish to.

As depression sets in, a person tends to withdraw and set up barriers of non-feeling as a protective measure. Retreating behind this wall of non-feeling results in a state of anhedonia: the inability to feel pleasure in things that the patient once found pleasurable. One of the skills of mindfulness is focusing on one thing at a time. By combining this skill with the skills of observing and describing, a depression sufferer is able to lower the barriers of non-feeling and again begin to experience pleasurable thoughts, feelings and activities.

A great deal of rumination involves anxieties about past events or worries about possible future events. MBCT draws on the mindfulness skill of being present in the moment. By focusing only on the “now,” an MBCT practitioner avoids the tendency to make assumptions about future events or to engage in regrets over past events. By living in the present, the patient breaks the rumination cycle that leads to deeper states of depression.

Another goal of the rumination cycle is to view negative moods as problems to be solved. This tendency leads to self-reinforcing cycles of negativity, especially if faced with an insoluble problem. Instead of trying to find a solution to the depression, MBCT teaches the patient to enter into being mode. From this mode, the depression is no longer a problem to be solved. It is simply a transitory state of mind. By learning to be still and wait for the depression to pass, the rumination cycle is broken. If there is no problem to be solved, then there is no need to find a solution, and there is no reason for the rumination.

Mindfulness and MBCT allow a person to become more aware of the patterns of thought and behavior that lead to her depressive states. By identifying these cycles and increasing awareness of them, she learns that such states are not things to be battled. They are simply transitory processes. As she comes to accept them as a part of herself, she comes to realize that fighting the depression only increases the depressive symptoms. But by engaging in being mode, she finds that there is nothing to fight.

MBCT Programs

MBCT programs are based on Kabat-Zinn‟s eight week Mindfulness-Based Stress Reduction (MBSR) program. Consequently, MBCT programs are usually eight weeks in length, and consist of one session per week, usually two hours long. A different skill is covered each week, and homework assignments are usually given in the form of directives. The goal of MBCT is to move patients from reacting to negative circumstances to responding to them. The goal of MBCT is not to find relaxation or happiness, but to learn to accept that negative thought and feeling cycles occur. MBCT teaches patients how to avoid getting drawn into self-reinforcing cycles of rumination and avoidance behavior.

MBCT programs are generally eight weeks long, and usually follow the outline below:

Week 1 consists of an introduction to mindfulness and an explanation of the foundations of the practice.

Week 2 teaches students how to cultivate patience and to become more aware of perceptions by using the skills of observing and describing.

Week 3 usually involves learning to shift from doing mode into being mode by ceasing to strive against emotional states. In this class, practitioners learn to minimize avoidance behavior. Basic mindful meditation skills are also usually taught at this time.

Week 4 helps students learn to differentiate between responding and reacting by introducing the idea of viewing their perceptions non-judgmentally.

Week 5 usually incorporates group reflections on how the practice of mindfulness has brought change to their lives.

Week 6 Incorporates a mindful walking meditation and lessons on communicating mindfully by being present and minimizing the tendency to avoid difficult topics of conversation.

Week 7 focuses on building trust and self-reliance.

Week 8 ends the series by encouraging students to continue learning. There is also a review and time for reflection from students and instructors.

Resources

CREST MBCT Training Seminars

Mindful Living Programs

Online Training in MBCT and MBSR

Mindfulness Across the Globe

List of links to Mindfulness-Based Cognitive Therapy Centers worldwide

Mindfulness-Based Cognitive Therapy

(Official Site of the founders of MBCT, Zindel Segal, Mark Williams and John Teasdale)

03.05 Mindfulness-Based Stress Reduction (MBSR)

Foundations of Mindfulness-Based Stress Reduction (MBSR)

Jon Kabat-Zinn, M.D. began using the techniques of mindfulness with his patients in the late 1970s and early 1980s. This work eventually led to the development of the Mindfulness -Based Stress Reduction (MBSR) program at the University of Massachusetts Medical Center. Since that time, there has been a wealth of research into the benefits of mindfulness. The seminal work by Kabat-Zinn on the use of mindfulness is Wherever You Go, There You Are (1994).

The program as designed by Kabat-Zinn combines mindfulness and yoga in an eight-week intensive training program. It began at the Stress Reduction Clinic at the University of Massachusetts Medical Center, and is now offered at over 200 clinics and medical centers throughout the world. Nearly three decades of research into MBSR and mindfulness continues to demonstrate the effectiveness of this approach in dealing with a wide range of both mental and physical health care problems.

What Is MBSR?

 MBSR is an eight-week intensive course in using mindfulness as a tool to reduce stress. Since its inception in 1979, over 20,000 people have completed the program. MBSR is heavily evidence-based. It is one of the more well-researched programs in history. It is also one of the most widespread stress reduction programs in the world.

The core concept of MBSR is to learn to step out of autopilot and to become fully aware of what is happening in our lives at any given moment. This is accomplished by moving from doing mode, in which our minds become preoccupied with completing the tasks of the day, and entering into being mode, where we simply allow ourselves to experience our perceptions of the world. By entering being mode we disengage from the “doing” activities of rumination and avoidance behaviors. We stop trying to find solutions to problems that may have no solution. We just allow ourselves the freedom to “be.” In gaining this freedom, we learn to let go of the stress that accompanies negative thought and feeling cycles.

Applications for MBSR

Kabat-Zinn created MBSR as a stress reduction program in 1979. Since that time, studies have examined the use of mindfulness in a wide variety of applications. Some of these include:

  • Astin (1997) found that mindfulness meditation increased sense of control over the practitioner’s life circumstances and enhanced their spiritual experiences.
  • Barnes, et al (2004) found that meditation helped to reduce blood pressure and heart rate in youth.
  • Brown & Ryan (2003) demonstrated that mindfulness increases a sense of wellbeing.
  • Carson, et al (2001) found that MBSR alleviated symptoms of stress in cancer patients, and also improved their overall moods.
  • Davidson, et al (2003) studied the power of mindfulness meditation to improve immune system functioning.
  • Kabat-Zinn (1982) studied the effects of mindfulness on the management of chronic pain. Although participants indicated that there was no decrease in the severity of the pain after participating, they did state that the practice of mindfulness allowed them to accept the pain. This led to better overall lifestyle ratings. A follow-up study in 1988 revealed similar results. Overall, participants were better able to regulate chronic pain after participating in mindfulness meditation classes.
  • Kabat-Zinn, et al (1992) showed that MBSR could be used to effectively treat anxiety disorders
  • Kaplan and Galvin-Nadeau (1993) studied the effects of MBSR n patients with fibromyalgia.
  • Kristeller & Hellett (1999) reported that mindfulness-based interventions were effective in treatment of binge-eating disorders.
  • Mills & Allen (2000) studied mindfulness of movement as a technique for helping victims of multiple sclerosis.
  • Reibel, et al (2001) demonstrated a positive correlation between MBSR and health-related quality of life ratings.
  • Semple, et al (2005) studied the utility of mindfulness in treating children with anxiety disorders.
  • Shapiro, et al (2007) looked at the effects of MBSR on therapists-in-training.

This is just a small sampling of some of the most recent research into the efficacy of MBSR in helping practitioners reduce stress and improve their quality of life. MBSR and mindfulness continue to demonstrate efficacy in a wide variety of applications for a large range of mental and physical health issues.

Theoretical framework of MBSR

The predominant model of behavior modification used by therapists and counselors is Cognitive Behavioral Therapy (CBT). CBT grew out of its predecessor, Behavioral Therapy. One of the tenets of Behavioral Therapy is that the mind is a “black box.” Since, theoretically, one cannot know the contents of another’s mind, therapists and behavioral scientists cannot know for sure which of their techniques are working and which are not. B. F. Skinner and his colleagues therefore conceptualized the mind and its processes as this black box, under the assumption that we can never know its contents. We can only study input and output into this system. In other words, we can only observe events and how a subject reacts to those events. By modifying the events, we modify the resulting behaviors. While this sounds good in theory, some of the conclusions of this line of thinking were uncomfortable. Since, according to behaviorism, only the results matter, a person with a severe mental disorder could be pronounced “cured” by simply modifying the behaviors that led to the diagnosis. A person with severe delusions could be considered “cured” under behaviorism if he were just trained not to talk about the delusions and not to behave oddly in public.

Films like Stanley Kubrick’s A Clockwork Orange, in which the protagonist undergoes a brutal and invasive behavior modification program to “cure” him of his sociopathic behaviors, and the gradual realization that a person’s cognitions play an important part in behavior modification, led to mental health professionals to re-evaluate behaviorism.

As behavioral scientists came to realize that what a person thought about a situation impacted that person’s behavior, a number of new therapeutic techniques, such as Rational Emotive Behavior Therapy, Rational Behavior Therapy, and Rational Living Therapy, began to appear. These models and others like them are known collectively under the umbrella of Cognitive Behavioral Therapy (CBT). The idea inherent in CBT models is that a person’s cognitions (thoughts) about a situation can influence their behaviors. A goal of CBT modes of therapy is to examine a person’s beliefs (cognitions) and to determine which of those beliefs constitute “thinking errors” that lead to undesirable consequences such as maladaptive behaviors. By restructuring beliefs about certain situations, behaviors can be changed.

Cognitive Behavioral Therapies have been hugely successful. By pinpointing the cognitions that need to be changed, patients and therapists are able to target these beliefs for modification. CBT modalities help to identify what needs to be changed, but there is often a missing component, and that would be how to change those beliefs. Mindfulness-Based Stress Reduction offers a path to change that is simple yet powerful. MBSR creates a space in which students can slow down the process of cognition and examine it step-by-step, while using the skills of observing and describing. As students learn to move from reacting to responding, they come to realize which behaviors they would like to change, and which they can simply accept as fleeting processes of the mind.

Research into MBSR shows that it can help reduce pain levels, diminish anxiety and depression, increase a sense of wellbeing, enhance relaxation, decrease psychological and physiological symptoms, increase the ability to act effectively in high-stress situations, and increase self-esteem and self-efficacy ratings.

Techniques of MBSR

 MBSR instructs students in a wide variety of meditative practices. One of the goals of MBSR is to increase our awareness of our present state. We go through many activities in life on automatic pilot. For example, prior to reading this sentence, were you aware of your own breathing? In the mindful breathing exercise from Section One we learned to be present in the moment by directing our attention only to our breathing. We can learn to increase our awareness by focusing on anything, but since our breath is always present, we use it as a means of increasing awareness of the present moment. This mindful breathing progresses to mindful sitting, in which we become aware of our body posture and all the sensations and perceptions that accompany it.

In the body scan meditation, students learn to increase their awareness of their own bodies. Our emotions reveal themselves in our bodies before they reveal themselves in our conscious mind. By becoming more aware of what our bodies are telling us from moment to moment, we become more aware of our emotional cycles as well.

In the mindful walking exercise, students of MBSR learn to apply their awareness skills to the simple activity of walking. By noticing what their feet and legs are doing at each step in the process of walking, awareness is increased. As we learn to walk mindfully, we come to realize that there are many daily activities that can be completed in a mindful fashion.

An MBSR program meets for eight weeks, usually in two or three hour sessions, once per week. In addition to these weekly sessions, participants engage in daily mindful meditations, either on their own, or through the use of guided audio recordings.

Resources

Center for Mindfulness at the University of Massachusetts

MBSR Workbook

Mindfulness Meditation New York Collaborative

Video Resources on MBSR

Oasis Institute

Become a MBSR Teacher

03.06 Mindfulness and Spirituality

Meditation and Religion

As you begin to introduce the concepts of mindfulness and meditation into your therapy practice, you may notice that some of your patients may be hesitant to meditate or practice mindfulness, especially if you live in an area where a fundamentalist religion is practiced. I began my practice in the Bible Belt, and I was surprised to discover that the word “meditation” is almost a dirty word here. In certain regions of the United States and the world, meditation is associated with cults and mysticism.

Jon Kabat-Zinn, in Wherever You Go, There You Are, had this to say about meditation and religious practice:

“When we speak of meditation, it is important for you to know that this is not some weird cryptic activity, as our popular culture might have it. It does not involve becoming some kind of zombie, vegetable, self-absorbed narcissist, navel gazer, “space cadet,” cultist, devotee, mystic, or Eastern philosopher. Meditation is simply about being yourself and knowing something about who that is. It is about coming to realize that you are on a path whether you like it or not, namely, the path that is your life. Meditation may help us see that this path we call our life has direction; that it is always unfolding, moment by moment; and that what happens now, in this moment, influences what happens next.”

–from Wherever You Go, There You Are: Mindfulness Meditation in Everyday Life

During my internship as a Marriage and Family Therapist, as I began to introduce the ideas of mindfulness and meditation into my clinical practice, I would occasionally come across a patient who felt that mindfulness was “the devil‟s work.” When I addressed this issue with my clinical supervisor, he advised me to simply use the techniques without referring to them as mindfulness techniques. As I began to do this, I noticed that the preconceived notions these patients had soon evaporated. I had eliminated the resistance to the therapy by not referring to it as mindfulness. By my doing so, the client was able to see the techniques for what they were, without any preconceptions or assumptions about their content.

Although mindfulness originated with Buddhism, it is not a religious practice. It is just a way of “falling awake.” Becoming more fully conscious of where you are and what you are doing at any given moment, you may enhance any religious practice. A careful reading of the Bible, or the Quran, or the Tao, or the Vedas, or most other works of a religious or spiritual nature, will reveal elements of mindfulness.

Spirituality

Somewhere between 90% and 95% of people on Earth practice some sort of spirituality. Obviously, spirituality must be pretty important. Studies tend to back this up. What the studies show is that the type of spirituality doesn’t really matter. Whether you’re Christian, Muslim, Jew, Buddhist, Hindu or Pagan, practicing some sort of spiritual path yields benefits.

Since the particular type of spirituality is secondary to the benefits gained (in other words, since all spiritual paths lead to a better quality of life for those who practice them properly), what is it about spirituality that allows it to work its magic?

Suppose you could take all the spiritual paths practiced worldwide, put them into a cauldron, and boil them down to their essence. What would remain? I believe that the common thread to all spiritual practices is a feeling of connection. Connection to others, or connection to the divine, or simply connection to nature and to ourselves. In short: Spirituality is a sense of connectedness to something greater than ourselves.

If you think back on the spiritual experiences you’ve had in your lifetime, do recall feeling connected on some level? Many describe spiritual experiences as a sense of oneness. Oneness implies connection to something outside ourselves. In this sense, even an agnostic or an atheist could achieve spirituality through connection.

Mindfulness doesn’t offer a path to a specific god or a specific divinity. What mindfulness does is to increase awareness and enhance the stillness so a practitioner may experience the divine in his or her own way. Think of the religious path as the highway, and mindfulness as the vehicle. Just as you may drive a vehicle on any number of roads, so you may use mindfulness to experience any number of religious paths more fully. Mindfulness is the tool that makes those connections possible.

Second-Order Change

One of the concepts of Cybernetic Systems Theory (a founding theory of Marriage and Family Therapy) is the idea of Second Order Change. Oftentimes, families get stuck in a “game without end.” Solutions that families use to overcome problems sometimes only serve to maintain the problem. When this happens, the family is caught in a feedback loop that perpetuates the problem. In such a case, playing by the unspoken and unwritten rules of the family does not lead to a solution. What is needed is a change in the rules of the game. Such a change is called a Second-Order Change.

How many of your natural assumptions prevent you from finding solutions to the problems you encounter in your day-to-day life?

Mindfulness is more than just a meditative technique. It is a way of seeing the world is it really is, without the filter of our assumptions and expectations. By viewing the world through mindful eyes, we experience a paradigm shift. This shift in perception allows us to change the things we can, and to accept the things we cannot change. Such a worldview is at the heart of every religious practice. It is also at the heart of most, if not all, forms of therapy and counseling.

Beginner’s Mind

Mindful Ecotherapy is a way of achieving beginner’s mind through nature and natural experiences. It allows us to examine the assumptions we have made about our world and how we exist in it. Some of those assumptions may be useful assumptions, but some of those assumptions may not be. By beginning each day with a blank slate, we erase those assumptions that may lead to results we don’t want.

How do you tell which assumptions are useful and which ones are not? The answer is that we use the mindful skill of focusing on one thing at a time to really pay attention to our thoughts and feelings, and to the thoughts and feelings of those around us. When using mindful awareness to examine our own inner motivations, we are able to discover which assumptions are useful in our daily lives, and which assumptions might need to be modified, or even cast away. Mindfulness is the wisdom to know the difference between the things we can change, and the things we must accept.

03.07 Course Summary

What is Mindfulness?

Mindfulness is a type of focused attention, sometimes described as “falling awake.” Kabat-Zinn (2003) refers to mindfulness as “paying attention on purpose, in the present moment, and non-judgmentally to the unfolding of experience moment by moment.” It is a way of leaving doing mode and entering being mode. Mindfulness is especially helpful in dealing with anxiety and depression.

Doing Mode vs. Being Mode

We are so accustomed to getting things done in our busy lives, that learning to stop “doing” is sometimes difficult. Mindfulness is a way to stop doing and enter into being mode. In being mode, rumination and avoidance behaviors cease, and there is less of a tendency to get trapped in self-reinforcing negative cycles of behavior.

Thinking mode is to doing mode as sensing mode is to being mode. Thinking is a thing that we do, where sensing (perceiving, participating) is simply a state of being.

 Wise Mind

When we are in a state of emotional dysregulation, subject to wild mood swings and being driven by our feelings, we are said to be in emotional mind. On the other hand, when we are using pure logic and reason, totally devoid of feeling and emotion, we are said to be in rational mind.

A goal of mindfulness is to achieve wise mind, which is a balance of emotional mind and rational mind in perfect harmony.

Observing

Observing can be defined as, “The mindful technique of directing attention to a particular event or activity, while not engaging directly in that event or activity.” Observing is a type of sensing the environment around you or your own inner state, or entering into being mode. It allows you to disengage from your thoughts and feelings, and simply observe them.

Describing

Describing can be defined as, “The mindful technique of focusing on the details of an event or activity, sensing the components of that activity, and then defining the experience without necessarily having to engage in the experience.”

Fully Participating

Fully participating can be defined as, “Living only in the present moment, devoid of thoughts, feelings or anxiety about the past or the future, while focusing only on the present moment.”

Mindful awareness allows you to experience every aspect of an activity. We have a tendency, when in thinking mode, to see things and activities as either “all bad” or “all good.” This is not necessarily an accurate depiction of reality. In reality, there is a little good in most bad things, and a little bad in most good things. Fully participating allows us to engage in all aspects of the present moment.

Being Non-Judgmental

We often act as if there is some objective standard of perfection that we are trying to live up to, but when we learn to be non-judgmental, we learn that perfection is subjective. Not only is it subjective, but we are the ones who define it ourselves. By being non-judgmental, we give ourselves permission to make mistakes once in a while. It is through our mistakes that we learn and grow.

Focusing on One Thing at a Time

Focusing your attention on one activity, and one activity only, such as enjoying each bite of a meal, is an example of focusing on one thing at a time. Mindful awareness allows one to become fully aware and to participate in every activity as if experiencing it for the first time.

The Power of Intention

The Power of Intention involves taking a solution-focused approach to problem-solving. If your intention is to carve an elephant, then you chip away anything that doesn’t look like an elephant. Mindfulness allows us to hone our power of intention so that our lives are lived deliberately, with purpose, and with full awareness, chipping away anything that doesn’t look like a purpose-driven life. From a therapeutic perspective, the Power of Intention works well with solution-focused forms of therapy, such as Narrative Therapy or Solution-Focused Brief Therapy, or Cognitive Behavioral Therapy.

Acceptance vs. Change

An example of the Acceptance vs. Change dialectic would be the Serenity Prayer, which states, “God grant me the serenity to accept the things I cannot change; courage to change the things I can; and wisdom to know the difference.” One of the paradoxes of mindfulness is that you must accept yourself as you are before you can change. This is summed up succinctly by Marsha Linehan as, “You’re perfect. Now change.”

Radical Acceptance

A question commonly asked in order to learn radical acceptance is, “What if this is as good as it gets?” This does not mean we are taking on a defeatist attitude; instead, it means recognizing that the purpose of life is not to avoid problems, but to learn to deal with them effectively in the moment.

Letting Go

Radical acceptance is used to facilitate the process of letting go. This means letting go of the anxiety associated with a problem, without letting go of the problem itself. When we have problems in relationships with others, a way of dealing with it is to remember the phrase, “Never overestimate your ability to change others; never underestimate your ability to change yourself.”

By realizing that we cannot change anyone but ourselves, we learn to let go of the need to try to change others.

Crystal Ball Thinking

Mindfulness involves paying attention only to the present moment, which is all we really have. If we are focused on worries about the past, or anxieties about the future, we are not living in the present moment. We cannot change the past, and unless we have a crystal ball, we cannot predict the future. When we try to do so, we are not living in the present moment; instead, we are engaging in Crystal Ball Thinking.

True Self

Descartes said, “I think, therefore I am.” Does that mean that if we stop thinking, we cease to exist? Of course not. We are not our thoughts or our feelings. What we are is the internal observer that watches our thoughts and feelings. This internal observer is called the True Self.

Mindful Breathing

Mindfulness is simply a heightened state of awareness. The practice of mindful meditation can focus on anything, but one of the first things a practitioner of mindfulness learns to focus on is the breath, since the breath is always present. By focusing on the breath and only on the breath, we leave the world of doing and enter the world of being.

Mindfulness-Based Cognitive Behavioral Models of Therapy

Cognitive Behavioral Therapy works to modify maladaptive thought and belief patterns commonly referred to as thinking errors. The theory is that by modifying the beliefs, the behaviors will change. These beliefs are what to change; Mindfulness is how to change the beliefs.

Acceptance and Commitment Therapy (ACT)

Acceptance and Commitment Therapy is a type of mindfulness-based therapy based on Relational Frame Theory (RFT). It is a type of Contextual Therapy that works to increase acceptance and to generate commitment to acceptance as a lifelong process.

Dialectical Behavior Therapy (DBT)

DBT was founded by Marsha Linehan as a method of treating Borderline Personality Disorder. It has four basic skill sets. These are:

  1. Mindfulness Skills
  2. Distress Tolerance Skills
  3. Emotional Regulation Skills
  4. Interpersonal Effectiveness Skills

DBT is based on the concept of the Hegelian Dialectic of thesis/antithesis/synthesis. It works to achieve a balance between polar opposites.

Mindfulness-Based Cognitive Therapy (MBCT)

MBCT was developed from MBSR as a means of preventing relapse in patients with clinical depression. Students of MBCT learn the specific states and conditions that leave them vulnerable to downward spirals of depression. MBCT also uses radical acceptance strategies to help patients overcome feelings of inadequacy that lead to cycles of depression. Research into the effectiveness of MBCT in preventing relapse (a return to depressive symptoms) demonstrates that the techniques of MBCT can reduce rates of depressive relapse by as much as 50%.

Mindfulness-Based Stress Reduction (MBSR)

MBSR was developed by Kabat-Zinn in the 1970s at the University of Massachusetts. MBSR is an eight-week intensive course in using Mindfulness as a tool to reduce stress. The core concept of MBSR is to learn to step out of „autopilot‟ and to become fully aware of what is happening in our lives at any given moment. MBSR and Mindfulness continue to demonstrate a wide variety of applications for a large range of mental and physical health issues.

Mindfulness and Spirituality

In certain regions of the United States and the world, meditation is mistakenly associated with cults and mysticism. This sometimes leads to resistance in treatment. One way of dealing with this resistance is to simply avoid using the term mindfulness. Another is to explain to patients that mindfulness is merely a way of heightening awareness. What mindfulness does is to increase awareness and enhance the stillness so a practitioner may experience the divine in his or her own way. Mindfulness is more than just a meditative technique. It is a way of seeing the world is it really is, without the filter of our assumptions and expectations. By viewing the world through mindful eyes, we experience a paradigm shift. This shift in perception allows us to change the things we can, and to accept the things we cannot change. Such a worldview is at the heart of every religious practice.