Walsh, M., 2003. Mind the Gap. Reformulation, Autumn, pp.22-24.
Remaining open to new therapeutic possibilities without being seduced by the next “fashionable” approach is a challenge. On the other hand CAT is valued as an integrative therapy which is continually growing and engaging in dialogues with other disciplines. More recent developments (for example, Vygotskian activity theory and infant observation research) are mentioned in the latest overview of the principles and practice of CAT, (Ryle and Kerr, 2002). Perhaps up until now the dialogues in which CAT engages in some ways imply or reinforce a divide between scientifically based practitioners working with what would seem to be more traditional skills and those who have developed other resources that could help our patients/clients.
There were a number of references to mindfulness in the last edition of Reformulation. (Summer 2003) Psychotherapists are increasingly turning to Buddhist meditation as a valuable treatment for a variety of problems including stress and depression. Although it is with some considerable trepidation that I refer to Buddhism at all, fearing that this may elicit misunderstanding, I can see no incongruity between the explicit, non-mystical approach to therapy that I value in CAT and the ideas that come from a treatment based on meditative practices originating in the Buddhist tradition.
Following the publication of a book, “Mindfulness-Based Cognitive Therapy for Depression” (Segal, Williams and Teasdale, 2002), which has been written by respected scientist-practitioners, and which is grounded within current psychological research, it might be timely to begin to think further about Tony Ryle’s invitation (challenge?) in his comments following last year’s conference. He asked if those who feel that specific methods from other approaches deserve wider use would provide guidelines for their place within CAT.
What follows is an invitation to CAT practitioners who are interested in integrating mindfulness-based therapy into their clinical work to join in debate and dialogue about how this might inform our CAT work in a way that enhances and complements rather than distracts or misleads. In order to put this into context, I will, as best I can, give some idea of how it is used in Mindfulness-Based Stress Reduction (MBSR) and Mindfulness-Based Cognitive Therapy (MBCT). I am interested in opening up a dialogue between CAT and include a few thoughts about how mindfulness might have a place within CAT, particularly in relation to what is being taught and how it is learned in CAT therapy.
It may be helpful at this point to separate the discussion of mindfulness from dialectical behaviour therapy (DBT), mainly because the perception of DBT as offering a “firm teacherly or authoritarian structure” (Tony Ryle ACAT News Summer 2002) is probably a long way from how many would like to think of the practice of teaching and learning mindfulness. (Preferring the reciprocal roles gently inviting to encouraged, accepted; kindly curious and interested to open and interested rather than benignly bossy to bossed about). Also there are probably many therapists interested in including mindfulness in their CAT work who, like me, have only a nodding acquaintance with the concepts of DBT. However, Marsha Linehan is the link between Williams, Teasdale and Segal as she introduced them to the training procedure called mindfulness which involved showing her patients ways of stepping back from their thoughts and emotions. The skill of mindfulness is a key component of teaching distress tolerance in her treatment manual for patients with a diagnosis of borderline personality disorder. Although mindfulness can be seen as the foundation skill of DBT, I think that the term is used in a reductive way that may mislead some about what it means.
What is Mindfulness?
Explaining mindfulness is a challenge and it is perhaps not easy to appreciate its value without engaging in it. It’s not an idea or a belief or a thought, it’s a practice. The dictionary meaning of mindfulness is awareness or paying heed. (“Mind the gap”). Mindfulness practice is a form of self awareness training that, although it is based on meditation techniques that have been around for over two and a half thousand years, is not dependent on any belief system or ideology. The relationship between meditation and mindfulness is that of means and ends. Meditation is a set of techniques for stripping away the distractions that make it hard to be fully minded or aware of what is happening in the present, on a moment by moment basis. Mindfulness is about intentionally becoming aware of our minds and bodies and the world about us while letting go of judgements about whether we like or don’t like what we find. Proponents of mindfulness say that its power lies in its ability to help people to become aware of, and ultimately free from, the restrictive and unhelpful thought patterns that can compromise their lives. (A clear and more detailed account of mindfulness can be found in Jon Kabat-Zinn’s foreward to “Mindfulness-Based Cognitive Therapy for Depression”).
Mindfulness-Based Stress Reduction and
Mindfulness-Based Cognitive Therapy
Mindfulness practice as a form of self awareness training has been adapted and developed into two approaches, Mindfulness-Based Stress Reduction (MBSR) and Mindfulness-Based Cognitive Therapy (MBCT). The use of mindfulness practice in health care was pioneered by Jon Kabat Zinn who founded the Stress Reduction Clinic at the University of Massachussetts Medical School. A treatment called Mindfulness-Based Cognitive Therapy, based on MBSR was developed as part of a recent 3 year randomised controlled trial in Bangor, Cambridge and Toronto. Zindel Segal. Mark Williams and John Teasdale have written a book “Mindfulness Based Cognitive Therapy for Depression: A new approach to preventing relapse.” (2002) which has at its core a report of this trial of a treatment that combines mindfulness meditation and cognitive therapy. The research showed significant reductions for depression relapse for formerly depressed patients to follow mindfulness treatment. The aim of the MBCT programme is to help individuals “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 core skill in the MBCT intervention is the disengagement of attention from mind states characterised by negative and ruminative thoughts. Cognitive therapist would usually try to help their patients to change negative or irrational thoughts, but the use of mindfulness emphasises a different way of relating to the way that all experience occurs, practising the noticing without judgement, clinging or aversion. The practice of cultivating a witnessing acceptance of the mind’s contents without responding to them develops a skill which can be used by individuals prone to depression relapse as a way of preventing negative thoughts from spiralling out of control towards even more negative thinking and ensuing depression.
There is the possibility of numerous benefits that follow from the formal practice that constitutes mindfulness practice, both for the therapist and the client. On a personal level I have found that both in using CAT and doing CAT I have become rather too busy, sometimes too preoccupied with thinking about TPPs and drawing out SDRs, particularly when offering the sort of brief CAT interventions that are useful to clients who may not want or need a full CAT. Practising mindfulness has helped me to slow down, notice feelings in the room. However useful, the use of the reformulation process and of other CAT tools does not necessarily mean that I am properly mindful if I fail to allow time to reflect, observe and pay attention to
The primary function of the CAT therapist is to promote awareness of any re-enactment of the procedures in the sessions and between sessions and this happens through the employment of a variety of techniques. CAT offers a clear model for showing clients how and why they have learned unhelpful ways of thinking, feeling and acting. Can teaching clients mindfulness in an explicit way which is pragmatic, focused and collaborative as described by Williams et al, (MBCT) help our clients with the tasks of CAT therapy and enable them to maintain the understandings of the therapy after it has ended?
Vygotskian ideas about how children learn have informed our understanding of our need to work within our clients' zone of proximal development (or zone of proximal personality development). CAT acknowledges that the idea of self-reflection, in the sense of thinking about one's own thought processes, is an unfamiliar activity for many people. One task of therapists is to provide concepts and experiences supporting the development of this capacity. Learning the skills of observing our own though processes from moment to moment can be likened to learning physical skills. When I am talking about this to clients I use the analogy of going to the gym. Meditation is like taking the mind to the gym. We don't just go once and assume that now we are fit. Perhaps mindfulness, a kind of tracking of our thoughts and feelings, might be regarded in the same way as the attainment of a basic level of fitness would be useful before going on a walking holiday, for example.
One benefit could be to help to engage the client in the task of focused attention and curiosity about themselves. It is a powerful experience to be aware of the therapist's attention and interest. If we seek explicitly to give clients tools and techniques for bringing this non judgmental curiosity to their own mental processes and if this was done alongside the CAT therapy early on in the therapy then they can be more easily recruited to the task of filling in the Psychotherapy File and other exploratory and self monitoring tools. The Psychotherapy File explains how to keep a diary of moods and behaviour but could clients be better equipped to carry out what is for many the unfamiliar activity of noticing? Perhaps in the early sessions we risk making the gap between what is available to a client and what can be achieved with our assistance too great and the scope of clients' self reflection should be paid more explicit attention during the early sessions. In the same explicit, non mystical way that we might teach clients certain psychological concepts about the way in which they relate to themselves and engage with others, explaining something about the formation of the self in early life in a way which is accessible, we could pay much more attention to the usefulness of learning to be mindful.
As well as helping clients during sessions leading up to reformulation, practising the skills of mindfulness and being non judgmental might help clients in the practice of recognition of problematic procedures in particular to get more of a sense of the observing eye some of us draw on SDRs representing the place from where recognition takes place.
Mindfulness taught properly could also help clients to internalise what is learning through the interpersonal experience, the movement through to revision or replacement. So, in a mindfulness exercise recently a client noticed clearly how impatient she felt and how irritated. These feelings were elicited in relation to another (me) who she experienced as being powerfully controlling as I slowly led the group through a body scan. She felt controlled and angry. The awareness of the strength of her feeling surprised her. Mindfulness means allowing these thoughts and feelings to occur whilst not latching on to them: (“Oh no, I'm feeling so impatient. Why am I always so impatient? It's bad I have to find a way of being more patient”) or using the thoughts or feelings to get caught up in a familiar story about oneself (“I am always doing that, showing my irritation. Other people don't like it. There was the time when…”) On this occasion as she listened to my instructions she became aware of her feelings but did not get caught up in judgment or criticism. This allowed her access to what were previously avoided feelings of shame and guilt. Here she was able to identify those uncomfortable feelings and also to stand back from them and let the feelings go.
What seems to be missed in MBSR and MBCT is a clear emphasis on the social and dialogic nature of the self as the basis for any understanding and treatment of human distress or dysfunction. Here CAT could offer these approaches valuable ideas about the crucial importance of reciprocal roles: perhaps they are missing an important understanding about why these approaches seem to work. Meditation is not a solitary activity as taught in MBSR and MBCT: it is taught in a group, with a facilitator who invite participants to, for example, focus on the breath, “as best you can”, who refer over and over to “gently and friendly awareness” Those reciprocal roles (gently inviting to encouraged and accepted; non-judgmental, accepting to not judged, accepted; curious and interested to curious and interested) are part of a therapeutic relationship within which clients learn to internalise a more benign way of relating to themselves with tools which can be learned and practised and would be understood within the understanding of the general theory of CAT so CAT therapists would also look out for ideal caregiver to ideally care for and for compliant, placatory or rebellious reciprocal role patterns etc.
The practice of mindfulness has great potential as a way of learning how to self-soothe. (Even if all clients learn of mindfulness practice is the Take 3 minute breathing space, p84, this could be useful in itself as an exit from many TPPs for many clients). We all need whatever support we can give ourselves.
I want to continue to think about how mindfulness can be used realistically. I would be interested, for example, to see what happens if clients joined a MBCT programme, having already had 3 or 4 CAT sessions and so could bring their road map into the group, or if clients attended in a 3 or 4 week mindfulness-based programme at some point during their CAT therapy. I would be very interested to hear how others are using mindfulness in their CAT work.
Further reading about mindfulness/useful contacts include:
North Wales Centre for Mindfulness
Institute of Medical and Social Care Research
University of Wales, Bangor
Kabat-Zinn, J. (1990) Full Catastrophe Living: using the wisdom of your body and mid to face stress, pain and illness. New York, Dell publishing.
Segal. Z.V., Williams. J.M.G, and Teasdale, J.D (2002) Mindfulness Based Cognitive Therapy for Depression: A new approach to preventing relapse. New York, Guildford Press.
Psychoanalysis and Buddhism - An Unfolding Dialogue (2003) edited by Jeremy Safran Boston, Wisdom publications.
CAT in dialogue with Mindfulness: Thoughts on a theoretical and clinical integration
Jayne Finch, 2013. CAT in dialogue with Mindfulness: Thoughts on a theoretical and clinical integration. Reformulation, Winter, p.45,46,47,48.
The Procedure Tracking Form (PTF): A Possible New Tool for CAT
Kingerlee, R., 2004. The Procedure Tracking Form (PTF): A Possible New Tool for CAT. Reformulation, Summer, pp.25-27.
ACATnews: A Fellow Scandinavian's Experience of the CAT Conference in Finland
Burns-Ludgren, E., 2003. ACATnews: A Fellow Scandinavian's Experience of the CAT Conference in Finland. Reformulation, Autumn, p.8.
ACATnews: Impressions from the International CAT Conference in Finland, June 2003
Curran, A. and B. Kerr, I., 2003. ACATnews: Impressions from the International CAT Conference in Finland, June 2003. Reformulation, Autumn, p.7.
Developing a Language for the Psychotherapy of Later Life
Hepple, J., 2003. Developing a Language for the Psychotherapy of Later Life. Reformulation, Autumn, pp.10-12.
Letters to the Editors: Agenda for Change and Psychotherapy
Nield, C., 2003. Letters to the Editors: Agenda for Change and Psychotherapy. Reformulation, Autumn, p.3.
Letters to the Editors: Association of Adult Psychotherapists (AAP)
Webster, M., 2003. Letters to the Editors: Association of Adult Psychotherapists (AAP). Reformulation, Autumn, pp.3-4.
Letters to the Editors: Dissertations and Reformulation
Toye, J., 2003. Letters to the Editors: Dissertations and Reformulation. Reformulation, Autumn, p.4.
Letters to the Editors: Psychoanalytic Perspective on Perversion Reformulated
Denman, C., 2003. Letters to the Editors: Psychoanalytic Perspective on Perversion Reformulated. Reformulation, Autumn, pp.4-5.
Using and Understanding of Primary Process Thinking in CAT
Sacks, M., 2003. Using and Understanding of Primary Process Thinking in CAT. Reformulation, Autumn, pp.30-32.
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