Mindfulness and CAT

Wilde McCormick, E., 2004. Mindfulness and CAT. Reformulation, Autumn, pp.5-10.


"A contemplative approach to psychological work differs from conventional therapy in being more concerned with the recovery of the presence of being – accessed through opening directly to experience – than with problem resolution”

‘Reflection and Presence’ John Welwood .
Journal of Transpersonal Psychology Vol 28 No 2

What is Mindfulness?

Mindfulness is a way of paying particular attention that originated in Eastern meditation practices. It has been described as bringing one’s complete attention to the present experience on a moment to moment basis. “Mindfulness is the awareness that emerges through paying attention, on purpose, in the present moment and non-judgementally, to the unfolding of experience, moment by moment”. (Jon Kabat-Zinn)

Mindfulness is the non-judgemental observation of the ongoing stream of internal and external stimuli as they arise. It means remaining present with what is, exactly as it is, without trying to avoid it, change it or disappear into it. The emphasis is upon maintaining one’s attention in an accepting non-judgemental way, in a spirit of unconditional friendliness to oneself.

 

The practice of mindfulness includes the body as participant, not the mind observing an observed body. It is through our bodies that we notice feeling, and experience change. Often our thoughts take us away from what we are actually feeling and experiencing.

Mindfulness practice focuses awareness upon a particular object, which then becomes the object of our mindfulness. Every action in our ordinary everyday life may become the object of our mindfulness. Cleaning teeth, washing up, waiting for BT, sitting in a stationary train, answering email.

Here are some examples of mindfulness practice.

Mindfulness of breathing

If we practice mindful breathing, we begin by placing the focus of our awareness solely upon the in-breath, its true nature, noticing whether it is a short or long breath, a harsh, smooth, or even breath. We follow the breath down with the out-breath, noticing its nature until there is no breath. The in-breath emerges naturally from this space.

Mindfulness of walking

The object of mindfulness begins with the soles of our feet as we place each foot on the ground. Our concentration then is upon the feel of the foot on the ground in our sock or stocking, the muscles of the foot and the way they extend up the back of the leg. We place the foot on the ground from heel to toe then release the foot from the ground behind us. As we walk, we become aware of each movement and everything that is involved in this movement.

Mindfulness of eating

In mindfulness of eating we place our awareness on the food before us – noticing first of all how our food looks, its colours, consistencies, what it consists of, where this food has come from, the elements present in its production – sun, rain, the planters and gatherers, transporters, packagers, shops. We may then remain present with the sensations as we place the food into our mouth, taking time to really experience it, without filling the fork with food for the next mouthful.

Right now, reading this, you might try practising mindfulness of reading. Placing your attention completely upon the words on this page and on your experience of these words, notice what resonates within you and try and remain simply with your experience of this. You might be aware of boredom, excitement, frustration, judgement, irritation, peace. In remaining in the present moment, with what is happening in our experience of this, we are engaging with the totality of our being, trying not to add to or distort this by thinking.

 

Another aspect of mindfulness practice is to engage in a spirit of curiosity and enquiry about our experience of the present moment. Trying to find the exact nature of our experience, being precise about it as we explore. There might be a feeling tone, or a sensation, there may be images, there will be thoughts, as well as distractions of mind such as thinking about something quite different, plotting what to do next, thinking about the past. There may be body sensations.

Mindfulness of emotion

Most poignantly for psychotherapy, the object of mindfulness might be emotional states such as confusion, anger, fear, longing, hurt, need. Our mindfulness would direct our attention to the emotion of confusion, or anger, and noting all that arose from the focus of our awareness. We might become aware of our thoughts around that particular emotion such as ‘this is not good’, ‘I’m no good’, and of thoughts about wanting to change emotion such as ‘I want out’ or disappearing into emotion such as ‘this will overwhelm me’ or about judging ‘I don’t like this’. These learned thought responses to emotion we do not like form the ‘false beliefs’ of traps, dilemmas and snags based on earlier experience and unrevised preconceptions.

 

If we experiment with remaining present with the experience of confusion, for example, this may reveal the nature of many distortions of thinking that defend us from feeling. The next step would be to allow ourselves to stop, pay attention, name and then remain with our experience, whatever it is. We may drop down into the simplicity of actual feeling – sadness perhaps, resentment, buried anger or joy or happiness. Then, we might rest in, and gain experience of, exactly what we are feeling without trying to change it by avoidance, resistance or by interpretation or analysis.

Whilst full blown emotional states take over our mood, getting used to the smaller rises and falls of feeling becomes like being with the waves of the ocean whose tides wax and wane. What we accomplish with our small steps of remaining present with actual feeling can free us from being lost in emotion.

Maitri

Mindfulness practice is taught in an atmosphere of Maitri – a Sanskrit word meaning unconditional friendliness to oneself, or non-judgmental loving kindness. This simple instruction is often a revelation to Westerners. Too often we find our internal world is dominated by conditional acceptance of ourselves, or by demanding, critical, judging internal voices:harsh, penetrating, putting down.

 

Maitri serves to offer us the best possible condition or environment for our practice, so that we can open to our experience as much as possible. When we are critical, conditional or judging, our minds restrict and close. When we stop and revise our tendency to automatic closure we open up to softening hardened attitudes. Mindfulness of breathing, sitting, walking, eating and feeling can subtly alter the quality of our experience.

Origins of mindfulness practice

Historically, mindfulness has been called the ‘heart’ of Buddhist meditation and resides at the core of the teachings of the Buddha.

 

The Buddha had nothing in the way of scientific instrumentation other than his own mind and body and experience. What emerged from his long arduous contemplative investigation was a series of profound insights, a comprehensive view of human nature and a formal ‘medicine’ for treating its fundamental dis-ease typically characterized as the three poisons: greed/grasping; hatred/aversion/avoidance; and ignorance/delusion/unawareness.

The dharma (dharma is a Sanskrit word carrying the meaning ‘lawfulness’ as in laws of physics, or simple Tao – the way things are as in Chinese Confucianism) that grew from the Buddha’s experience is at its core, truly universal. These universal teachings are not categorized in terms of belief, ideology, or religion. They form a coherent, phenomenological description of the nature of mind, emotion and suffering, its potential release, based on highly refined practices of learning to cultivate mindful concentration; mindful remaining present with what is.

How does mindfulness work in practice?

Try another little experiment now, as you read this.
Sit in a chair and rest your attention upon your breathing.
Allow any sensations in your body into your awareness, just as they are, without judging or dismissing.
What is actually going on in you right now?
What are you adding to that based upon how you are thinking about it?

Mindfulness in clinical practice

John Teesdale in Mindfulness Based Cognitive Therapy writes:
“dysfunctional attitudes - false beliefs born of experience – lead to enduring traits. The depressed thinking programme does not get properly wiped from the hard disc – small shifts in mood can reactivate it, as if it had never been absent. Mindfulness fosters a de-centred relationship to mental contents by training people to take a wider perspective, in order to observe their thinking as it is occurring.”

 

John Kabat Zinn, in Full Catastrophe Living writes: “It is remarkable how liberating it feels to be able to see that our thoughts are just thoughts and that they are not our “reality”.

Research into mindfulness based clinical practice has been mostly in the United States. Mindfulness as a form of self-awareness training has been adapted from its spiritual tradition into secular life and developed into three main approaches.

The use of mindfulness practice in health care was pioneered by Jon Kabat Zinn twenty years ago when he founded the Stress Reduction clinic at the University of Massachusetts medical school. He took groups of patients suffering from both physical and emotional pain that had not been relieved by traditional means and taught them mindfulness practices over a period of eight weeks. His programme has been extremely successful and has continued since the 1980’s. Each weekly group meeting lasts two hours and patients are taught mindful yoga stretching, body movement, mindful walking, breathing, and mindfulness of sound, emotion and the arising of thought. They are encouraged in small groups to enquire in detail about the nature of their experience. In this way they flush out distortions of attitude and thinking that compound their pain. Each member of the group has individual telephone contact with the mindfulness instructor.

A treatment called Mindfulness Based Cognitive Therapy, based on Mindfulness Based Stress Reduction was developed as part of a 3-year, randomised control trial at Bangor, Cambridge and Toronto. The research showed significant reduction for depression relapse in formerly depressed patients. The aim of MBCT programme is to help patients “make a shift in their relationship to the thoughts, feelings and bodily sensations that contribute to depression relapse, and to do so through changes in understanding at a deep level.” The programme is suitable only for relapse patients and not for patients with a first onset of depression. Three professionals, Zindal Segal, Mark Williams and John Teessdale, authors of MBCT for depression, began the work with great scepticism but accepted the basic premise that to include mindfulness in ones therapeutic approach required one to have an established mindfulness based practice of one’s own.
Marsha Linehan, behavioural psychologist and researcher in the US, took a year to study in a Zen monastery in Japan before creating Dialectical Behaviour Therapy. She apparently jokes that it would not have been a good career move to call her treatment Zen Behaviour Therapy. Her mindfulness based work with borderline self-harming patients holds in balance the nature of the paradox ‘you are perfect as you are – and you’ve got to change.’ Again the emphasis is upon the patient’s learned negative thoughts that are to be unlearned, a process of change accompanied by the underlying emotional distress being regularly bathed in the energy of mindfulness.

In each of these three treatment modalities, the roots of mindfulness are always acknowledged and instructors and practitioners of mindfulness based health care must have their own developed mindfulness practice before they can take patients.

My own Mindfulness practice

I have, for a number of years, and through the influence of my interest in Transpersonal Psychology, worked from a contemplative perspective. My own mindfulness meditation practice is an important part of my daily life. It is a discipline of silence and concentration, and my experience is that it nourishes the ground of consciousness from which I work therapeutically. It has always been challenging. When I first started I thought I would always be distracted by thoughts about past or future, and often this is so today. I learned that everything that happens is part of the practice, and that it is unhelpful dualistic thinking to divide experience into good or bad. There is no ‘good’ practice, only one’s experience. Although some experiences are infinitely more preferable than others!! Sometimes my practice is full of unwanted, demanding thoughts, sometimes my body aches and screams, sometimes I feel near to being awash with feeling. The discipline of the practice itself and the non-judgemental enquiry give ground and boundary for accepting whatever comes. I try not to judge the content of consciousness (although I often find myself self-critical). The by products of practice are more spaciousness around difficulty or confusion, some calm and groundedness, some sense of finding a still centre, a place to return to.

Learning mindfulness practice we work initially with something straightforward such as the breath or mindful movement in order to train ourselves for more complex areas such as emotion and mind.

Mindfulness within CAT

The core skill of mindfulness based cognitive therapy is the disengagement of mind states characterised by negative or ruminative thoughts.

 

The practice comprises cultivating a witnessing acceptance of the mind’s contents without responding to them. Mindfulness can be an empowering self-help skill that is simple to learn with a willingness to practice regularly. It can be seen as a branch that hangs just above the swirling river of experience that does not negate the power of the swirling river but allows us to experience it and be alongside it at the same time. Patients learn that emotional pain rarely stays the same without being fed by thought. This is awful….this will never get better…they should not have done this to me it’s their fault…I can’t move from this….I am useless, bad, so angry that I will burn everyone up in my sight.

MBCT, MCSR and CAT all name the following as counter-indicators for the collaborative work: a recent psychotic break; active substance abuse and suicidality; being very recently traumatized.

Can these ideas work within individual psychotherapy and within a therapeutic relationship?
 
I first thought of offering mindfulness within CAT because of the return of a depressed patient whom I had seen five years earlier, who had had repeated admissions for extreme panic attacks and near mute depressive symptoms and undergone extensive ECT treatment.

She has kindly given her permission for the following account of her first year of mindfulness based CAT to be published.

F

F and I are meeting for the first time in a number of years. She completed her first CAT work with me some five years ago. I have received a letter from her consultant asking for her to have more therapy and she has made the appointment herself. She brings me up to date with what has been happening. It seems as if she has spent much of the last year as an inpatient, suffering severe bouts of depression, returning home for short periods and having a great deal of ECT.

I ask her what she thought more therapy could offer her now. She says:
“All I am doing is distracting myself all day in order to get to bedtime when I can take a pill and go to sleep”

 

I remain silent with this powerful statement, its self-observation, insight. I feel deeply sad and sit for a moment with her statement and my feelings, letting them be fully present in the room. She bursts into tears. “I realise I am absolutely desperate.”

We explore the nature of her desperate feelings together. What’s it like?

She describes waking feeling ‘low’. I sense in myself that this is a learned generality offered to her so many times as an inpatient. I want to know more, the exact nature of ‘low’. She does not understand. Where do you feel it in your body? She looks surprised and cannot tell me. She looks scared. Then she says

‘Tired. I feel weighted down. In a cage, covered by a blanket. When I wake up, I think ‘there’s another day to be got through’.
We sit. She rocks slowly forward and back sitting on the edge of my sofa. She rubs the back of her left hand with the right.

How does she cope?
I hug my husband. Go for a drive. It takes up the time.

How bad does it get?
When it gets to tea time and my husband isn’t there and I feel panic coming on I can’t stand it and I ring the hospital. If it gets too bad they say to come back in.

The constant pain. Then there’s not wanting to do anything. I just want it all to end.

Again the room fills with her desperate feelings.

She says she wants therapy to reacquaint her with the maps we made years ago in the CAT . She feels she’s lost her way. She wants therapy to be a place where she can bring her suicidal feelings and not have them judged or shut away.

“I’d never do it because of the children and H. But they terrify me and I’m frightened they might take over.”

We discuss practicalities. I discover and feel shocked that she has never shown her diagrams to her psychiatrist or his team. We talk about the splitting we mentioned in the first therapy between the difficult but admired medical model and the comfortable but secretly despised therapeutic model. Both models she subjected herself to passively, with hidden feelings of aggression. She looks frightened, as if these revelations will lead to her being punished and rejected by me. The tension of her ambivalence and hidden rage is painful. I remind her of how difficult it was for her, so dominated by the placation trap and need to be admired, to feel angry with either myself or her psychiatrist when things went wrong or didn’t work out, medications, my absences etc, now ECT. She ‘knows’ that unresolved anger is often under depression. I know that when I name how hard she is on herself that she knows it and that there can be a perverse pleasure in it, as in the masochistic wound described by Johnson in Character Styles (1992). It seems as if the choice to avoid the fear of abandonment and rejection by others has meant that she abandons and rejects herself, living a half-life.

Her suffering is immense. And now there is so much identification through illness, and identity as a patient, with dependency on admired professionals.

I wonder how much she can realistically do in therapy. I am aware of not wanting to collude with being yet another professional trying to help whom she must outwit and endure in order to preserve the sense of self she does have. Her initial statement of naming her activity as distraction from desperate feeling has attracted me. I know whatever we agree to do together must be time limited and offer her something only she is in charge of. I decide to describe mindfulness to her as a self help tool she can learn, and tell her we can experiment together to see if this gives her any advantage in terms of control over impossible and overwhelming mood. I emphasise the experimental nature of the work we will do. I tell her about the course I am undertaking and that I have a mindfulness practice of my own. I emphasise the ‘not going anywhere or trying to achieve anything’ aspect of mindfulness, and the collaborative work of CAT where we will work closely with her diagrams, and each time we meet make new ones of each process she is describing.

In my notes afterwards I write: She presents in a very depressed way. Her body is motionless except for the rhythmical rocking and hand rubbing. Her mouth is dry from medication. Her hair, once curly and full, is flat against her head. She remains sitting in her anorak. She looks at me only furtively except when she was able to tell me how desperate she was. Her breathing appears almost non-existent. She speaks in a faint whisper. I am aware of her watching me all of the time through her pores, as she is not looking directly at me. I remember how passive she became in the earlier work we did, how authority figures became powerful people to please and also rebel against.

Her husband drives her because her medication has affected her eyesight.

I write to her psychiatrist:

“X and I have agreed that the therapeutic work needs to be extremely focussed and practical in order to help her find strategies to respond to the depths of her depressed mood and suicidal thinking when she is inside it. So far she is finding the mindfulness practices helpful. They are designed deliberately to not achieve anything or try and get anywhere. The instructions are to remain simply present with what is happening, in the here and now. She is picking up a lot more on her patterns of negative thinking and rumination that maintain her gloominess. I think it is essential that the therapeutic work is not orientated to achieve any specific ‘success’ or desired state for others. If she can learn some self management via mindfulness and thus gain some relief from the intensity of her depression this may offer some respite and be a tool she might take into the future.”

During the initial four sessions I teach her some basic mindfulness of breathing. We sit together and breathe. I teach her the finding of her seat, shoulders down, head supported by an invisible string, feet flat on the floor, hands flat on thighs and to concentrate on the rising of the in-breath and falling of out-breath. We sit together for just five minutes.

She takes home written instructions, taken from Mindfulness Based Cognitive Therapy, of how to sit each day for five minutes, morning and evening. She is to experiment with where in the house to sit: to not try any more than five minutes and to write detailed feedback about what it was like. Words that describe the experience, exactly as it was: bland, difficult, painful, noisy, boring, soft, harsh. Her words, whatever they are.

She fulfils these tasks diligently and writes neat and precise feedback of her experience, exactly as she finds it. As she goes through the feedback in our sessions she sees for herself the power of her patterns of negative thoughts. A second self awareness homework is to monitor her ‘low’ mood and her feelings of resentment. Then to monitor her awareness of thoughts and responses around the word ‘pain’. Then to experiment with making the feeling of body pain the object of her mindfulness practice. Whenever she feels panic she is to return to the in-breath and out-breath. She becomes more aware of her anticipation of emotional challenges and how this incites hyper vigilance.

Our work coincides with her beginning to take tai-chi classes organised by her Day Centre. She finds these helpful and grounding.

We work for six sessions weekly and have a month break during which she is to practice mindfulness of breathing for ten minutes twice daily and introduce a fifteen minute walking meditation we have done together. She has diagrams of the loops that extend from ‘feeling crushed and insecure’ through ‘antennae heightened and extended to what others think’ to the cognitive distortion of ‘if someone doesn’t meet my eye contact I must have done something wrong’ and then falling into feeling bad, feeling depressed and panicky. She has exits of recognition and revision, of breathing into her fear to stop it escalating.

When she returns she has made a new exit on her diagram, noting ‘this is where it all starts’ on her core state of crushed/insecure. She has been working on remaining present with this and to allow others whatever feelings they may have that may not be related to her. There is a relief in this. She acknowledges that it is more difficult to bring her mindfulness practice into feeling states such as crushed/anxious and to frustration and, most difficult of all, anger. Anger is something she is terrified of and cannot bear to get near.

We meet for six more weekly sessions and then have a six week break. After this we arrange to meet once each month.

Just before I go away on holiday she telephones saying that she has had two dreams in which she has taken an overdose and wakes in fear of whether she has done this or not. I ask her about her current feelings. She responds that she just wants the pain to stop; that she wouldn’t do anything because of the children and her husband, but she doesn’t trust herself. I wonder with her if the mindfulness practice has ‘flushed out’ these most difficult feelings for her conscious awareness, and she brings them to me now, on the eve of my holiday.

At first she apologises as if she is a great nuisance. I say that these feelings are here, in the edgy ‘catch me if you can’ way in which they inhabit her and that we must remain with them here and now on the telephone, just as we are. She is able to tell me more of what she feels inside, of how frustrated she is at how little she can do, how bad she feels, how angry she is with her depression. Can she express how terrible and self destructive she feels without having to kill herself?

I ask her if she has made any plans in her mind of what she might do. She answers by saying she has pills in the house and that she will take them to Boots. I ask her to be fully conscious of what she is choosing to do. I feel that the ‘good’, placatory, dutiful but passive, angry and resentful self would do the ‘right’ thing, but that the hidden, raging self wants its rage and fury to be heard. We talk about choosing to remain conscious about what we feel and the terms on which we live, to have control over all decisions especially whether we live or die and that no one can do this for us. I cannot stop her killing herself but I can help her maintain conscious awareness of her thoughts and feelings as she is talking about this decision so that her life really is in her hands.

When we next meet, after my holiday, she tells me that a few days went by before she chose to go to Boots and hand in all her pills. She recognised and dared to acknowledge and take charge of her angry feelings and what she did with them. She felt a small surge of energy as she decided to live on her terms – not ‘ideal’ but not rubbish either, but somewhere in that slither of everyday conscious life that initiated her telephone call - and handed in the pills.

We have maintained our monthly meetings since September of last year. We continue to sit together at the beginning and end of sessions and she brings me the work she has done on self-awareness exits on her diagrams. She has given her consultant, whom she also sees monthly, copies of her diagrams and her mindfulness records. She has bought her own singing bowl.

She still suffers considerably from depressed feeling and thinking, and themes of suicidal thinking in waking and in dream life continue to occur and are part of our sessions. As yet she has not had any further admissions. It’s possible that the mindfulness practice, for now, is offering her a small space within which she may find relief from the deep woundedness she inhabits.

But we shall see.

This is currently work in progress and my thinking about it is as follows: The combination of CAT and MBP combine two complementary approaches. CAT offers the accurate description of currently endured pain and the learned thinking that maintains the emotional suffering. The practice of mindfulness serves potentially as a way of allowing some extra space around the narrow restricted repertoire in a non-judgemental attitude. It is something the patient can actively do themselves through their daily practice, and might just give them some ground upon which to both observe their suffering and - maybe - to enter the denied, feared emotional state. The space created by the practice of mindfulness may allow a patient to become more aware of the deterministic and repetitive nature of their cognitive distortions, how they repeat, how they build up into rumination and how sometimes they might be able to achieve a ‘just drop it’ position.

A by product of mindfulness may be greater relaxation and calm. The most positive gain in my experience is the possibility of control and non-judgemental experience inside of oneself: and potentially, a different relationship with suffering.


Further reading
Epstein, Mark GOING TO PIECES WITHOUT FALLING APART. Broadway 1998

Epstein, Mark THOUGHTS WITHOUT A THINKER. Basic Books 1995

Glassman, Bernie BEARING WITNESS. Bell Tower 1998

Kabat-Zinn, John FULL CATASTROPHE LIVING using the wisdom of your body and mind to face stress, pain and illness. Dell 1990

Kabat-Zinn, John WHEREVER YOU GO THERE YOU ARE mindfulness meditation in everyday life. Hyperion 1994
Kornfield, Jack A PATH WITH HEART. Bantam 1993

Linehan, Marsha SKILLS TRAINING MANUAL FOR TREATING BORDERLINE PERSONALITY DISORDER. Guildford 1993

McCormick, E Wilde LIVING ON THE EDGE. Sage 2002

Nhat Hanh, Thich ANGER, WISDOM FOR COOLING THE FLAMES. Parallax Press

Rosenberg, Larry BREATH BY BREATH. Thorsons 1998

Segal, Williams and Teasdale MINDFULNESS BASED COGNITIVE THERAPY FOR DEPRESSION. Guildford Press 2002

Wellings, N and McCormick E Wilde TRANSPERSONAL PSYCHOTHERAPY theory and practice. Continuum 2000

Welwood, John AWAKENING THE HEART Shambhala, Boston 1983

Zohar, D and Marshall, I SPIRITUAL INTELLIGENCE; THE ULTIMATE INTELLIGENCE. Bloomsbury 2000

Tart, Charles LIVING THE MINDFUL LIFE. Shambhala, Boston

Wilber, Ken ONE TASTE. Shambhala, Boston 1999

Full Reference

Wilde McCormick, E., 2004. Mindfulness and CAT. Reformulation, Autumn, pp.5-10.

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