It sometimes seems as if there isn’t a psychotherapy seminar or workshop anywhere in the country that doesn’t have “mindfulness” in the title, yet most therapists these days are still vague about how they can use mindfulness techniques, minute-by-minute, in sessions, and how guiding clients through mindfulness exercises can help resolve difficult, long-standing issues. So what follows is a brief primer on the specifics of incorporating mindfulness into therapeutic practice.
Let’s start with a basic question: what is mindfulness? According to Jon Kabat-Zinn’s pathbreaking 2005 book, Wherever You Go, There You Are: Mindfulness Meditation in Everyday Life, mindfulness is awareness with intention and without judgment of what’s happening—as it’s happening—in the present moment. As with other forms of therapy, the application of this concept requires the structure of selected tools and techniques.
In my work, I draw on two body-oriented mindfulness methods, Hakomi and Somatic Experiencing: the Hakomi Method, originated by Ron Kurtz, helps clients tap into core beliefs held below the level of conscious awareness; Somatic Experiencing, developed by Peter Levine, focuses on resolving traumatic activation in the nervous system. Using these methods, I guide clients into deeper states of body awareness. In the moment-to-moment experience of sensation, movement, and images, clients learn how their nervous system organizes itself around old patterns, and how to experiment with new ways of being.
Through mindfulness-based therapy, my clients gain three essential skills: self-regulation (the ability to be self-aware and to self-soothe in situations of emotional intensity); self-state awareness (the ability to identify habitual coping strategies and step out of them); and self-compassion (the practice of diffusing shame and self-criticism through a deeper form of self-acceptance).
Introducing Mindfulness to Clients
My work with Suzanne began two years ago. At the time, she was in an emotionally abusive relationship with Ken, who raged at her regularly. Over and over again, she tried to walk away from his tirades, but panicked every time about losing him, caved in, and accepted the abuse. She came to therapy, in her words, “to learn to value myself.”
For about five months I worked with Suzanne using my own style of talk therapy, informed by my training in Self Psychology. Suzanne experienced me listening to her carefully and empathically, implicitly valuing her needs and feelings. Through this and other supports in her life, especially a group of devoted friends, she finally found the strength to leave Ken. “I really want to be happy,” she declared, “and I won’t let myself be squashed anymore.”
“Suzanne,” I said, “can I invite you to try something that may help you take in the words you just said much more deeply?” She looked at me curiously and nodded. I explained that certain experiences go deeper into the nervous system when we apply mindfulness. I invited her to close her eyes (assuring her she could open them anytime she needed to), and to feel her feet on the floor, her hands on her knees, and the breath entering and leaving her body.
After about five minutes of guiding her through the awareness of different bodily sensations, I said, “OK, Suzanne, I’m going to invite you to repeat the words you spoke earlier—‘I really want to be happy’—and to notice how you feel in your body as you say this.”
Slowly, she repeated the words and, after a pause, said, “I feel my shoulders just drop way down. My belly is breathing more fully. This feels good, like how I want to feel—solid. What is this called, what we’re doing now?”
“We’re using mindfulness to help you really take in this new possibility of solidity, to anchor this important way of experiencing yourself.”
“Great,” she said, opening her eyes and smiling. “Whatever it is, let’s do more of it.”
Why did I choose this particular moment to introduce mindfulness to Suzanne? First, I was looking for a moment that would likely yield a positive experience of mindfulness, so as to set the stage for future mindfulness-based work. Second, I was waiting for the therapeutic relationship to feel strong enough. In doing mindfulness-based work, the therapist is essentially inviting clients to explore a new way of experiencing themselves, so there must be sufficient trust and rapport.
For the next few months, we practiced mindfulness techniques, integrated into regular talk therapy, which taught Suzanne to “resource” positive experiences of herself. She began looking forward to the times she could close her eyes, go inward, and feel better about herself.
At this stage, for clients who like to understand what we’re doing, I explain how mindfulness works. I tell them that the part of the brain we use to think about our world, the prefrontal cortex, is only a recent evolutionary development. The thinking brain gets eclipsed by the limbic (“emotional”) brain, patterned by early experiences in relationships, and by the reptilian brain, concerned with basic survival. Then I translate for clients a simplified version of Daniel Siegel’s theory of the mindful brain, explaining that mindfulness allows access to parts of the limbic/emotional brain that aren’t engaged as effectively just by talking.
It wasn’t long before Suzanne’s enthusiasm for this first foray into mindfulness work began to wear thin. “I come in here, and have these great experiences, where I feel relaxed and clear,” she said one day, clearly frustrated. “But then I go out on a date with a guy, and I can’t find that calmness in myself anywhere.”
I acknowledged her frustration and suggested that we start to apply mindfulness in a new way that might help her in her dating life. She was skeptical, but curious.
“Suzanne, can you tell me what your experience is like when you’re waiting to hear from the man you’ve just had that first date with?”
“Oh, it’s like I can’t stop going. I get edgy and fidget and clean the house and just keep thinking, ‘If I don’t call, he’ll make plans with someone else.’ It’s terrible!”
The things we do in life that get us into trouble are usually done when our nervous systems are highly charged or activated. Outbursts of anger, compulsive behaviors, sudden decisions—these reflect an overactivated and temporarily deregulated nervous system. In mindfulness-based therapy, we teach clients to track their level of activation as a first step toward self-regulation.
“I can see that even as you talk about this, you seem agitated. How would you rate your level of agitation, on a scale of 1 to 10, with 1 the calmest you’ve ever felt and 10 the most agitated?”
“I’m about a 6 right now—not nearly as bad as I get when I’m at my worst, waiting for the phone call. Then I’m about an 8 or 9.”
“OK, so it’s not as bad as sometimes. . . . Do you feel OK about exploring this?”
“Yes,” she said, “I’m good to stay with this.”
“OK, can you identify where in your body you feel the agitation?
“It’s in my belly—that awful grinding feeling. Also in my jaws—I’m clenching them. And my breath is shallow and tight; it feels crappy.”
“Yeah, not such a good feeling! Is it OK to stay with this?” I waited for a nod. “So, let yourself bring a gentle awareness to the grinding feeling in your belly, the clenching in your jaws, and the tightness in your breath. Stay with all that and notice what happens next.” I waited in silence as Suzanne went inward.
“I notice things start to ease up,” she said. “My breath returns. It’s like another part of me is saying it’s just going to be OK.”
These are powerful moments. We often find that by simply staying with an uncomfortable experience and bringing a gentle awareness to it, the experience shifts on its own. We start to realize we don’t have to fight against what’s been scaring us.
For several more months, Suzanne practiced this kind of mindfulness. I assigned homework: for example, to track her level of activation after the next date with a man. She used the 1-to-10 scale to track the sensations in her body. When she noticed herself getting more than a 5, she practiced resourcing herself. First, she tried just bringing awareness to a part of her body that wasn’t agitated. If that wasn’t enough, she called up an image that had been powerful for her in the therapy session; for example, her grandmother, who’d always been there for her. In the most difficult situations, she engaged in an activity, like going for a walk, which actively disrupted the increasing agitation.
All good therapies use the therapeutic alliance as an opportunity for the client to internalize positive relational experience and learn self-soothing from the support that comes from the relationship. In mindfulness-based therapy, we also develop the client’s capacity to attend directly to disruptive internal experience and bring to bear their own self-regulatory capacities.
Suzanne could now track her activation after a first date and resource herself so she didn’t alienate her potential partner. But how would we address the underlying vulnerability that triggered her intense anxiety in the first place?
The search for a way to change core developmental patterns could be described as the holy grail of psychotherapy. In The Mindful Brain, Daniel Siegel suggests that mindfulness has the capacity to build bridges between the limbic centers of the brain, which store emotional patterns from childhood, and the observing and contextualizing capacities of the prefrontal cortex. Here, Siegel is pointing us in the direction of the grail: the possibility of witnessing old emotional patterns without being compelled by them. But how do we actually apply mindfulness to achieve this integration?
Several weeks later, now a year into our therapy, Suzanne staggered into my office in tears. She dropped onto my couch in despair. “I’m in the middle of it now. This is how I get. I’m just waiting to hear from Harvey, the guy I told you about last time. I can barely keep myself from calling him.” She identified a pounding in her chest and a “terrible, warm, dead feeling” in her legs.
I asked, “Do you remember when I suggested to you, a few sessions ago, that we could drop even deeper into this experience, find out what it’s really about for you, and perhaps unwind the knot that keeps you bound in this pattern?” I’d planted the seed for this deeper level of work, knowing that only Suzanne could decide when she was ready. All the resourcing we had done so far had prepared her for this next step.
“Yeah,” she said sullenly, “I’m ready to try that.”
“OK, Suzanne, I’m going to invite you to tune in to your body, close your eyes if that helps, and become aware of the simple sensations of sitting on the couch, your feet on the floor, the air touching your skin. I know you’re feeling a lot of distress, the pounding in your chest, that ‘dead’ feeling in your legs. See if you can also be aware of something slightly pleasant, or even just neutral.”
“I guess my hands feel OK,” she said. “They’re just touching each other, kind of soft.”
“Great, let yourself just be with that OK feeling in your hands.” I saw the tension in her face start to ease.
To go deeper into the caverns of the psyche, we need anchors. The fact that she could locate this more tranquil feeling and respond somatically to it signaled to me that we could go forward.
“So now, let yourself feel the pounding in your chest, and the warm, dead feeling in your legs, knowing you can come back to your hands anytime you want to.”
“It’s like a throbbing in my chest,” she responded. “A deep, red color goes with it. It feels like a bottomless pit. It’s all I can do just to feel it, without freaking out.”
“But you’re with it now; it’s not overwhelming you completely. . . . You’re doing great. . . . Stay with it . . . and notice if something feels familiar about it.”
“I have an image of the nanny I had when I was 2 years old; the one who left abruptly,” she said. Tears were coming down Suzanne’s face. “I loved her so much.”
Suzanne had told me about this nanny, and later nannies, who’d left. Another key part of the picture: a mother who usually wasn’t attentive to her emotional needs.
I noticed that Suzanne’s right hand was extending slightly, palm rotating just a little toward open. “Your hand is coming out,” I said gently. “I’m right here with you.” She nodded.
“What do you notice as your hand starts to open in this way?” I asked.
“My other hand is coming out now, too, to comfort the first hand,” she said.
“Yes. . . .” I responded. This was a very tender moment.
“It’s holding that hand the way I like to hold my cat’s paws when she’s sleeping,” Suzanne said.
“It’s so gentle,” I added, before a long pause.
“Suzanne, can you feel how you hold the cat’s paw?” She shifted into a posture to do this.
“It’s like the way I hold an infant,” she said. Her left arm and hand were now contacting her heart.
“Yeah, let’s stay with this a while. Feel yourself holding that infant.” More gentle silence. “Now, see if you can feel yourself as the infant being held,” I prompted.
We’d dropped into what the Hakomi Method calls the “missing experience”: the key developmental need that didn’t get met sufficiently in childhood. A tiny part of the nervous system has frozen itself in time, still waiting to get the need met, and a larger part of the nervous system has constructed defenses, coping mechanisms, character strategies—what could be called “self-states”—to cope with this fundamental absence.
For Suzanne, the missing experience involved soothing by a caretaker in the face of a profound loss. No one had done that for her when she’d been an infant or a child. So she never internalized an ability to self-soothe. She constructed a self-state based on the inevitability of sudden loss and the impossibility of soothing. In this state, she could do nothing but collapse, and then judge herself deficient. Now, by reaccessing that “frozen” part of the nervous system that was still waiting to be soothed, we could finally attend to the underlying need, the missing experience she’d been waiting for all this time.
Suzanne started to open her eyes. “I feel so different,” she announced. Her eyes were wide open, taking in the room. Her breath was going more deeply into her body. Her head and neck were rocking ever so slightly.
“Yeah, take your time and really feel how this does feel different,” I said. We took plenty of time for Suzanne to orient herself to this new self-state—a state of being that allowed for the possibility that her deep places of distress could be soothed, and for other changes that could flow from this. Our task now was to support her as she experienced herself grounded in this new state.
I instructed Suzanne to now notice everything she could about her body—first, how she felt in her chest and legs. Her chest was no longer pounding, she said, and her legs felt energy moving through them. Then I invited her to notice her breath, her spine, her eyes, her jaws, her belly. I asked her to notice how she saw and heard the outside world from this place. I also asked her to notice how she experienced herself sitting across from me.
Finally, I asked Suzanne to imagine waiting for a call from Harvey from this new place.
“It’s so different. I’m OK in myself. I don’t need him to call for me to be OK,” she responded.
We continued to support the new self-state by discussing how she could apply it in relationship with others. Could Suzanne still be as present with herself while she was talking to me? Did she need to take a few moments to reconnect with herself from time to time? Could she imagine relating to others from this place?
Now that she’d experienced this new self-state and had an embodied template for it, she could use this as a reference marker in her life to remain conscious of whether she was in her usual self-state or in this different, calmer one. This is what I call “self-state awareness.”
I invited Suzanne to take some time later in the evening to reflect on our session, and to feel herself back in her body. Journaling, walking in nature, art—all these could be ways to reconnect with the new self-state. More homework was to become aware of when the habitual self-state reemerged through bodily cues, thought processes, and the other elements that made it so familiar.
Suzanne described her new ways of being in relationship as a “newly discovered continent.” Metaphors can be helpful for identifying self-states, and recently, I’ve been finding landscape metaphors particularly useful for enhancing mindfulness. Jagged cliffs of isolation, dry deserts of longing for intimacy, flowing rivers carrying new life to verdant plains of relational possibility, congested cities that simulate sexual arousal but feel emotionally vacant—these are examples of how metaphors can evoke greater internal awareness and contribute to a deepening mindfulness. In any good psychotherapy, we survey these internal landscapes. In mindfulness-based psychotherapy, we learn the features of these landscapes as signified by specific bodily experiences. Having journeyed to these different landscapes in the therapy room, our clients are able to notice which landscapes they inhabit at any given time.
Clients report that becoming physically aware of the current internal landscape, or self-state, empowers them, in the words of one client, to “transport out.” Being somatically aware of a self-state accompanying an experience allows us to witness the experience as an experience—not the totality of ourselves. This is the liberation of self-state awareness: we can witness habitual tendencies, but not be controlled by them.
Exploring habitual self-states will almost always bring up self-judgment and shame. Shame comes from a deep-seated fear that the underlying vulnerability (around which the painful self-state was created) reflects a fundamental inadequacy. Most people spend much of their lives running from their underlying vulnerabilities and the rejection they imagine coming from other people who might witness them. Self-judgment emerges both from our resentment of the habitual patterns that cause us pain and as a way to attack ourselves before someone else can criticize or reject us for our weaknesses.
Because the dynamics of shame and self-criticism are so strong when working with core-level vulnerabilities, mindfulness-based therapy must promote self-compassion. We have two main tools with which to do that. First, we seek to help clients learn how the habitual self-state originated as a response to difficult dilemmas. As Suzanne became aware of how impossible it had been for her as a young child to deal with sudden losses and a lack of parental soothing, she could bring compassion to this younger, more vulnerable part of herself. She learned that when the habitual self-state showed up (which she could now identify through the accompanying bodily experience and behavioral/cognitive patterns), these core vulnerabilities were asking to hear her own kind voice and feel her caring. The grueling moments of waiting for the phone call are still not easy for Suzanne, but she’s learned to be gentler with herself, and now dates with far less anxiety. More and more, she views the dating experience as an opportunity not only to start a romance, but also to develop a more solid sense of herself.
The second tool we have to promote self-compassion in our clients is our own compassionate presence. The practice of mindfulness isn’t inherently compassionate—it can be plagued with disinterest, dissociation, and negative self-judgments. Here, the therapist plays a crucial role. I believe that clients actually model the feeling tone of their own mindfulness around the feeling tone of their therapist’s voice. Because mindfulness-based therapy can take clients so deep into core-level experience, the therapist’s compassionate presence profoundly impacts how clients come to observe their inner world.
In essence, the therapeutic task is to model compassion and understanding as we guide clients through their pain-filled internal landscapes, learning how previous self-states were adaptive for earlier life stages, no matter how much distress they may have produced. We must recognize that all these landscapes—no matter how dangerous, strange, frightening, or sad—are always part of our common geography, the places we’ve all visited at one time or another. Longing for intimacy, pulling away from people, getting needs met in self-destructive ways, shielding our hearts—we all share these all-too-human states. For exploring these wilder shores of the self, we can take no more promising a journey of discovery than in the vessel of our own mindful body awareness. Our great privilege is that we, as therapists, have the opportunity to guide our clients on these journeys.
By Wendy Behary
The appreciation for the mind-body relationship is thoughtfully articulated by Shai Lavie in this case study. He offers a clear strategy that’s accessible and easy to assemble within the framework of our theoretical allegiances. The emphasis on establishing safety and trust in the therapy relationship is an especially important element when working with early-attachment ruptures and trauma processing. Lavie discusses the value of an attuned “voice,” one that expresses empathy and a compassionate presence, allowing the client to go deeper into her personal story to discover early unmet needs at a felt level of experience.
Empirical support for attuned, contingent communication and a felt sense of connection to and with our clients is beautifully described in Daniel Siegel’s books The Developing Mind and Parenting from the Inside Out. Jeffrey Young, the founder of Schema Therapy, also strongly proposes that therapists become a “reparenting” model for the vulnerable side of the client, within the limitations of the therapy relationship, helping the healthy adult side to grow and nurture the “child.” Further, research has shown how patients with borderline personality disorder learn to heal extreme childhood wounds and develop healthy coping modes when the therapist takes the role of a needs-meeting, reparenting figure for the vulnerable or abandoned child side of the client, utilizing emotion-focused strategies, such as imagery and bodily awareness, to reach deep into core experiences.
Lavie’s case deftly chronicles the treatment journey from an identification of self-defeating beliefs linked to bodily sensations, to self-soothing strategies for regulating distress during triggering episodes, and the discovery of early-childhood emotions that become reactivated in conditions of perceived abandonment and deprivation. Despite harrowing times of despair when dating, Suzanne had a “devoted group of friends” and seemed to have some resourcefulness and the ability to be a quick study. However, this isn’t always the case for clients with abandonment and deprivation issues.
Many with borderline personality disorder are more severely impaired, avoidant, and isolated. They feel resentful when coached to soothe themselves, as they’ve experienced a lifetime of having no one but themselves to rely on. They desperately attempt to cope with pain and loneliness, only to perpetuate the same destructive outcomes. They long for someone else to lend a shoulder, or as one of my clients used to say, “Someone to help pull the wagon … just once in a while.”
I’m not sure that these clients, after five months of “talk therapy,” are prepared to sustain emotional self-reliance in meeting their unmet needs. Even Suzanne, who appears a little sturdier, demonstrated a “worn thin” enthusiasm after a short while, according to Lavie. The effective strategy for resourcing her inner world was his use of imagery, which enabled her to construct a safe anchor to her grandmother, and the “dropping even deeper” into somatic awareness-imagery, which linked her “loss” experience (her nannies’ leaving her) to feelings that were replicated when waiting for a call back from a new date. The recognition and reinforcement of her “calm hands” in meeting her need for holding, affection, and security was nicely integrated into the imagery as well.
Lavie’s work elegantly demonstrates the most basic and powerful element in his success with Suzanne: filling the voids with steadily attuned presence and encouraging support, mentoring, and guidance—“getting” her and helping her to “get” little Suzanne. Careful and timely execution of the strategies Lavie proposes is obviously an important factor to consider during the assessment phase of therapy. Bringing attention to bodily sensations can assist clients (especially those in detached and overwhelmed states) in unlocking the door to their emotional world and achieving discernment, tolerance, and resilience as they confront the phantoms that still visit them.
Wendy Behary, L.C.S.W., the founder and director of The Cognitive Therapy Center of New Jersey and The New Jersey Institute for Schema Therapy, has been treating clients and training professionals for more than 20 years. She’s the author of Disarming the Narcissist: Surviving and Thriving with the Self-Absorbed.
Illustration © Sally Wern Comport
Shai Lavie, MA, works with adults, adolescents, and families in private practice in San Rafael. A Certified Hakomi Teacher on the faculty of the Hakomi Institute of California, he leads transformational groups with adults and teens that integrate Hakomi, Somatic Experiencing, group process, ritual, and Jungian dreamwork.