Q: I’m trying to get my clients to meditate, but it isn’t working. Any suggestions for working with especially vulnerable clients?
A: Clinicians often make a variety of mistakes while trying to introduce mindfulness, and in my 30 years of trying to figure it out, I’ve made all of them. So let me share some of my bloopers with you in the hopes that you can avoid them. After all, meditation teachers often say, “This practice is simple, but it isn’t easy.”
Myth 1: Always Start with the Breath
I know this is what they teach in meditation classes, but with a clinical population this isn’t always a wise place to start. Let me tell you about my experience with Kayla many years ago, before we knew much about mindfulness meditation or trauma. She was a new patient and was anxious about an upcoming job interview. I thought some deep breathing would help her relax, so I asked her to take a number of deep breaths. After a few minutes, she began to hyperventilate and became angry with me. I was confused. How could a simple relaxation practice go south so quickly? It turned out she had a trauma history that she hadn’t disclosed and was in the middle of a flashback of being suffocated by her father. Starting with the breath had triggered her memory of struggling to breathe. So please make sure you take a thorough history before attempting to introduce mindfulness to your clients. It’s often best to start with a meditation on sounds or on sensations at the periphery of the body, which are less likely to evoke an adverse reaction.
Myth 2: Keep the Eyes Closed
Closing the eyes can be scary for vulnerable clients, and it’s not a good idea to ask them to do that right away—a mistake I made with my client Margaret many years ago. I knew she had trouble feeling safe, but since we had a good alliance, I thought it was okay to teach her some simple mindfulness exercises to help her with her tendency to ruminate about the past. However, when I asked her to close her eyes and bring her attention to the soles of her feet, I discovered she was more fragile than I realized. “But what if there’s an animal hiding under this couch?” she protested. “What if something happens when my eyes are closed? What if someone breaks in?” Since then, I’ve modified things for fragile clients. Before teaching simple practices, I have them keep their eyes open and ask them to look around (and under my couch, if necessary) to assuage any fear about safety. I respect hypervigilance, keep practices short—three to five minutes at most—and don’t include long periods of silence. Again, this is not what they teach in meditation classes.
Myth 3: You Have to Sit Still
Most people think you have to sit still to meditate. This isn’t the case. For many of my vulnerable clients, mindful movement can be a powerful tool to help them push forward, in therapy and in life. Barbara, for example, was an obese adolescent who struggled with depression and addiction. She didn’t like to be in my office at the city hospital where I worked, and she didn’t like to talk. Fifteen minutes into one seemingly interminable session—during which she sat silently except to inform me that all my questions were “stupid”—I had an idea.
“Let’s try an experiment,” I suggested. “Let’s move this session outside.” I then taught her walking meditation as a way to develop a new relationship with her body. We started by walking slowly, side by side, not talking, but simply feeling each footstep as it touched the ground. To my surprise, she liked it. It soon became a refuge for her, and she’d practice it when she needed a break from the constant fighting with her parents at home. Over time, she began to open up and talk. I realized that by trying to get her to talk, I’d become, in her eyes, another intrusive mother. Walking with her, rather than interrogating her, shifted the dynamic. For the rest of her treatment, she’d come to my windowless office, take a look around, and then say, with an impish grin, “Let’s blow this joint.”
Myth 4: Mindfulness Is Always a Good Idea
There’s a psychoanalytic maxim that the right intervention at the wrong time is the wrong intervention. The same holds true for mindfulness. Years ago, when I was still a young therapist, I’d just completed an inspiring mindfulness retreat. I thought mindfulness was the answer to all human suffering, and like the proverbial carpenter with a hammer, to whom everything looks like a nail, I saw the potential for sharing this new therapeutic tool with just about every patient.
On Monday morning, still enthusiastic, I greeted a new patient. She seemed to be a perfect fit for a mindfulness-based approach, which I was sure would help with her chronic depression, and I couldn’t wait to teach her what I’d just learned. After taking an initial history, listening to her chief complaint, and seeing no glaring contraindications, I suggested that we try some meditation. I asked her to sit quietly and go inside. What I hadn’t realized was that her parents were always telling her to sit still and be quiet. She wanted to talk and wanted someone who would listen. By introducing mindfulness before establishing a relationship, I’d inadvertently reenacted the dynamic with her parents. She decided then and there that I wasn’t the right therapist for her, and our first session was our last.
Myth 5: Expect Quick Results
The reason it’s called mindfulness practice is that it takes time and repetition. Just as you can’t learn tennis or how to play the piano in one lesson, mindfulness skills develop over time. Research shows that changes in the brain usually take six to eight weeks of daily practice. Our clients aren’t going to feel significantly better after one session, so patience and persistence are necessary. Difficult emotions and painful memories are guaranteed to arise. If a client isn’t open to facing a bit of personal discomfort, mindfulness probably won’t be a good fit.
Chris entered treatment in pain over the end of his marriage. At first, he wanted to blame his ex-wife: she was controlling, she’d gained weight after the birth of two kids, and she was no longer interested in sex. He didn’t want to look at his role in the end of the relationship or examine his behavior in any way. He just wanted to move on and find someone new.
He’d heard about mindfulness and thought it’d be good to try. He liked the idea of “becoming Zen,” as he put it, because he wanted to be happy, calm, and peaceful. However, as he began to practice, disturbing thoughts and memories of the demise of the marriage began to arise. It was hard for him to sit with the discomfort. “I don’t have time for this crap,” he said. “I don’t want to mourn. I just want the pain to go away.”
In response, I tried to help him get curious about how he may have contributed to his relationship difficulties. “I know that it’s hard to sit with all these feelings, but what comes up when you do?” I asked. With time, considerable effort, and consistent practice, he learned to recognize, sit with, and work with difficult emotions, rather than simply deny or avoid them.
Myth 6: You Need to Do It Alone
Many clients shy away from meditation, believing that it’s a solitary pursuit. But it isn’t. In fact, insisting that clients practice by themselves can be a major stumbling block to consistent practice. Many try it and feel overwhelmed by the onslaught of thoughts and emotions, or they’re uncomfortable with the silence. We’re social creatures, and most of us have difficulty being alone. So encouraging clients to join a class, especially in MBSR (Mindfulness-Based Stress Reduction) or MBCT (Mindfulness-Based Cognitive Therapy) can be helpful, as can suggesting they listen to one of many meditation downloads or apps available online.
A therapist once asked me how to wean her clients from meditation aids such as CDs and audio downloads, thinking it wasn’t real meditation if they weren’t doing it alone. Just as a child attaches to its mother to get nourishment, most of us find it beneficial to connect with a teacher (previously recorded is fine), who can inspire and nurture.
Myth 7: No Pain, No Gain
Perhaps the best piece of advice for helping people stay with mindfulness is to have them find something enjoyable in the practice. If it’s torture for them to sit and be aware of their thoughts or feel their breath, they won’t continue to do it. So you might introduce walking meditation instead. Or you could suggest loving-kindness or compassion meditation—traditional practices that involve the silent repetition of certain phrases, such as “May I be happy. May I be peaceful. May I be free from suffering,” designed to cultivate positive states of mind. Above all, do your best to make sure that the practice fits the patient.
The Zen master Thich Nhat Hanh was once asked how to keep a practice going. “Do you want to know my secret?” he responded with a smile. “I try to find a way to do things that is pleasurable. There are many ways to perform a given task, but the one that holds my attention best is the one that’s most pleasant.” So collaborate with your clients to find exercises that are both accessible and enjoyable. And if you make a mistake or two, don’t worry: the Zen masters joke that life is just one mistake after another.
Photo by Alena Darmel/Pexels
CategoriesClinical Practice & Guidance In the Therapy Room Professional Development Issues & Developments Clinical Skills & Experience Mind, Body, Brain Professional Development
Earn CE Credits
Just for reading the Networker!