Introducing Mindfulness in Therapy

Helping Clients Bring Mindful Awareness to Anxious Thoughts and Sensations

Shai Lavie

By Shai Lavie

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.

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.


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.”

“Okay, so it’s not as bad as sometimes.... Do you feel okay about exploring this?”

“Yes,” she said, “I’m good to stay with this.”

“Okay, 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 okay 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 okay.”

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.

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.

This blog is excerpted from "In Search of a Lost Self" by Shai Lavie. The full version is available in the September/October 2011 issue, The Mindfulness Movement: Do We Even Need Psychotherapy Anymore?

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Illustration © Ralph Butler

Topic: Mindfulness

Tags: Mindfulness | body | breathing exercises | coping | guided mindfulness meditation | Jon Kabat Zinn | meditation mindfulness | regulation | self-compassion | self-criticism | self-regulate | shame

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