01 - 16. Integrating Mindfulness into CBT

16. Integrating Mindfulness into CBT

M indfulness has been studied intensively, sometimes as a standalone intervention and sometimes as part of a psychotherapeutic modality. In fact, mindfulness has been practiced for thousands of years. Many researchers have studied the effectiveness of mindfulness for a host of problems, including psychiatric disorders, medical conditions, and stress (see, e.g., Abbott et al., 2014; Chiesa & Serretti, 2011; Hofmann et al., 2010; Kallapiran et al., 2015), as well as relapse prevention for depression (Segal et al., 2018). In this chapter, you’ll find the answers to the following questions: What is mindfulness? Why use it with clients? What is formal versus informal mindfulness practice? Why should you practice mindfulness yourself? Which techniques do you use before introducing mindfulness? How do you introduce mindfulness? How do you do mindfulness of the breath, and what do you do afterward? What is the AWARE technique for worry? WHAT IS MINDFULNESS? One definition of mindfulness, reached through consensus by experts, is maintaining attention on immediate experience while taking an INTEGRATING MINDFULNESS INTO CBT

orientation of openness, acceptance, and curiosity (Bishop et al., 2004). It teaches you to focus on what’s currently happening, either externally (such as talking to someone) or internally (such as your thoughts, emotions, or bodily or mental sensations), and you practice being willing to experience whatever is happening in a nonjudgmental way. Mindfulness is particularly useful when clients are engaged in a maladaptive thought process, such as obsessing, ruminating, worry, or self-­criticism. It is also quite useful when clients are fearful of experiencing certain internal stimuli such as negative emotions, thoughts, images, cravings, or pain. Mindfulness helps you develop a different relationship to your thoughts. Instead of engaging with them by, for example, questioning their validity, you note their presence (without judgment) and allow them to come and go on their own. The goal is not to eliminate the unhelpful thought or eliminate distressing internal stimuli—­that is usually impossible and quite maladaptive. Instead, mindfulness helps you nonjudgmentally observe and accept your internal experiences, without evaluating or trying to change them. In other words, you learn to focus on the present moment while being open, accepting, and curious. There are several kinds of mindfulness. Here are three of them:

1. Mindfulness of thoughts: for clients who excessively ruminate, worry, or try to suppress intrusive thoughts or images.
2. Mindfulness of internal stimuli: for intense emotion and other distressing internal experiences.
3. Mindfulness for self-­compassion: for clients who experience a great deal of self-­criticism. In this chapter, we’ll cover mindfulness of thoughts, using a focus on the breath, specifically for clients who engage in depressive rumination. Abe’s Ruminating Here’s a typical scenario in which Abe ruminates. He’s sitting on the couch in his living room, watching television. But a series of depressive thoughts runs through his head and interferes with his concentration. “Why am I watching TV? I should be looking for a job. I’m wasting my life. What a failure I am. I used to have a good life, but everything has turned bad. There’s no hope. I’ll never feel better.” These thoughts repeat over and over. They lead to sadness and hopelessness and a heavy feeling in his body, they undermine his confidence and motivation, and he continues to sit on the couch instead of engaging in valued action. Cognitive Behavior Therapy: Basics and Beyond

Initially we evaluated these thoughts, and Abe felt some relief in the session. But despite practicing strong responses to them at home, the thoughts kept coming back. Abe, like a certain percentage of depressed clients, was engaged in the unhelpful thought process of rumination and had trouble disengaging from it. He believed: “If I think hard enough about why I lost my job and my wife, I can figure out how to avoid bad things like this in the future.” “If I can figure out how I got depressed in the first place, I’ll feel better.” He also worried to some degree and held the following belief: “If I predict problems, maybe I can prevent them from occurring.” These beliefs may be functional in certain situations but become highly dysfunctional when they lead to the recurrence of the same negative thoughts over and over again. After a period of time, Abe developed another dysfunctional idea: “Once I start thinking this way, I can’t stop.” Mindfulness helped him change that belief. Responding to his thoughts was important, but it just wasn’t effective enough. After learning mindfulness, Abe was able to recognize when he was ruminating, accept the experience and his negative emotion, and then choose not to engage with his thoughts. Initially, he learned to do this by focusing on his breath and later was able to focus on his external experience. FORMAL AND INFORMAL MINDFULNESS PRACTICES There are two types of mindfulness practices: formal and informal. In a formal mindfulness meditation, you set aside a period of time (e.g., 5 to 60 minutes), go to a quiet place, and focus your attention on a particular experience (e.g., the breath, different parts of the body, movement, thoughts, emotions, external objects, or sounds); you notice when your attention has wandered from the specified experience and nonjudgmentally bring it back to the experience. We recommend that many clients practice formal meditation for 5 minutes or so initially. They are much more likely to keep up a formal mindfulness practice if it’s brief. We also recommend informal practice, which is applying the principles of mindfulness to your day-to-day experiences, focusing on what you’re doing or what is happening at the moment in an accepting,

Integrating Mindfulness into CBT

open, and nonjudgmental way. When your mind wanders to the future or past and it’s not helpful to think more into it, bring it back to your current experience. Also, upon noticing an unwillingness to experience unwanted thoughts, emotions, and/or sensations, take note of the experience(s), allow them to be present without trying to control them, and bring your attention back to the task at hand. SELF‑PRACTICE I’d like to encourage you to do what I do, that is, to use mindfulness yourself. I do a formal, 5-minute mindfulness exercise most mornings (focusing on my breathing). I do informal mindfulness at various times during the day, for example, when eating, brushing my teeth, or taking a break at work. Looking at nature and experiencing it through my senses helps me let go of anything on my mind, like work or current stressors in my life and appreciate my surroundings. When my mind wanders, I bring it back to my immediate experience. You can be mindful of almost any experience, such as walking, driving, doing tasks or chores, or engaging in self-care activities. I also do formal (if it’s feasible to meditate for 5 minutes at the time) or informal mindfulness when I find that I’m caught up in a cycle of unhelpful thinking. I would advise you to take up the practice of mindfulness yourself too for three reasons:

1. It can help reduce stress and enhance your sense of well-being.
2. It can help you understand and describe the technique to clients.
3. It can help motivate clients to practice it when you use self-­ disclosure about the benefits you’ve experienced. TECHNIQUES BEFORE INTRODUCING MINDFULNESS Some CBT therapists teach mindfulness as a standalone skill. But we’ve found that integrating it into CBT treatment is much more effective for clients. Here are important strategies to use with clients before you introduce mindfulness, using depressive rumination as the example:
4. Educate clients about the cognitive model.
5. Examine advantages and disadvantages of rumination versus the advantages and disadvantages of focusing on the present moment Cognitive Behavior Therapy: Basics and Beyond

(and using alternative skills like problem solving and mindfulness, when needed). 3. Use Socratic questioning to test the accuracy of what they see as the advantages of rumination. 4. Discuss how rumination interferes with their ability to live life according to their values. 5. Educate clients about how mindfulness can be helpful for their thought process. 6. Have them start the thought process right in session. 7. Ask them to rate the intensity of their negative emotion. Then guide clients through the mindfulness exercise, for about 5 minutes, while recording it (so they can practice at home). After the mindfulness exercise, use the following strategies:

1. Ask clients to re-rate the intensity of their negative emotion.
2. Guide them in drawing conclusions about the experience (to further modify their dysfunctional beliefs about the thought process).
3. Collaboratively set an Action Plan item, typically practicing the formal mindfulness for about 5 minutes every morning, and then briefly using the strategy as informal mindfulness to disengage from rumination during the day. There are two reasons we want clients to engage in the unhelpful thought process before starting an exercise such as mindfulness of the breath:
4. The exercise can serve as a behavioral experiment to test dysfunctional beliefs—­for example: “Rumination is uncontrollable.” Clients learn that the mindfulness exercise gives them a degree of control over their rumination—­which motivates them to practice between sessions.
5. It’s important to replicate the conditions clients will experience when using this strategy outside of session. If I had taught Abe mindfulness during a therapy session when he was somewhat relaxed, he may have returned the following week reporting that mindfulness didn’t help throughout the week when he was distressed and ruminating.

Integrating Mindfulness into CBT

INTRODUCING MINDFULNESS TO CLIENTS Next, I start a mindfulness of the breath practice with Abe. Judith: It sounds as if rumination isn’t actually helpful. Is that right? Abe: Yes. Judith: I’d like to tell you about mindfulness. It’s a technique that helps you reduce rumination by noticing your thoughts nonjudgmentally and disengaging from the thought process by letting the thoughts come and go while turning your attention to other things in the present moment. Abe: Okay. Judith: First, we need to get the rumination going so you can experience the same thoughts right now that you have at home. Can you sit back and close your eyes? If you’d rather, you can keep them open though. Abe: (Sits back and closes his eyes.) Judith: (Pauses for 5 seconds.) I’d like you to start thinking about your life and your future again, either to yourself or out loud, just like you did when you were sitting on the couch this weekend: how you should be looking for a job, how you’re wasting your life, what a failure you are, how you used to have a good life but everything has turned bad, and how there’s no hope and you’ll never feel better. (Pauses for 30 seconds.) How are you feeling? Abe: Pretty sad. Judith: On a 1 to 10 scale? Abe: About an 8. Next, I turn on the audio recording app on his phone. Judith: Now, keep your eyes closed. I want you to focus on your breathing, on the sensations you feel as you breathe. (Pauses for 10 seconds.) Notice how the air feels going in and out of your nostrils; how your lungs, chest, and abdomen feel as they expand and contract. (Pauses for 15 seconds.) You can notice the sensations as a whole (pause) or focus on a specific sensation like the air going in and out of your nostrils, whichever is most comfortable to you. (Pauses for 30 seconds.) As you do this, you’ll notice that your mind is going to wander, various thoughts will show up, or you’ll get caught up in rumination from a minute ago. As you become aware of this, gently bring your focus back to the breath. (Pauses for 45 Cognitive Behavior Therapy: Basics and Beyond

seconds.) No matter how many times your mind wanders, every time, just become aware that it’s happened, and gently bring that focus back to the breath. (Pauses for 30 seconds.) There’s no need to criticize yourself or get frustrated when your mind wanders because that’s what our minds do; all you have to do is notice it’s happened and gently bring that focus back to the breath. (Pauses for 40 seconds.) It’s okay if you notice thoughts in the back of your mind. You don’t need to force them away or make them any different. Just notice they’re there and let them fade on their own, as your main focus is on those breathing sensations (60-second pause). TECHNIQUES AFTER A MINDFULNESS EXERCISE Next, I stop the recording, tell Abe he can open his eyes, and then ask him a series of questions. “How intense is the sadness now, 0–10?” “How was that for you?” “What did you notice?” “Did your mind seem to wander?” “Were you able to bring your attention back to the breath?” (If yes, ask) “What does that tell you about your ability to let go of rumination?” “What happened to your emotion as you practiced mindfulness?” “What do you make of that?” “Was this helpful?” “Do you think it would be good to practice this for your Action Plan?” You should encourage your clients to use either formal (if feasible in the moment) or informal mindfulness exercises when they find themselves stuck in an unhelpful thought process or caught up in an uncomfortable internal experience. It’s useful to learn a variety of formal mindfulness exercises so you can select the one that looks as if it will be most effective for an individual client (see, e.g., Hayes et al., 2004; Kabat-Zinn, 1990; Linehan, 2018; McCown et al., 2010; Segal et al., 2018). To more fully learn about integrating mindfulness into CBT, step by step, and view videos, visit beckinstitute.org/CBTresources.

Integrating Mindfulness into CBT

THE AWARE TECHNIQUE This mindful technique was designed to be used when clients worry excessively (Beck & Emery, 1985) and/or experience excessive anxiety. You can adapt it for angry or depressive rumination. Here are the steps:

1. Accept the anxiety (or other emotion).
2. Watch it.
3. Act constructively with it.
4. Repeat the steps.
5. Expect the best. These steps are described in Appendix C. To teach clients to use this technique, ask them to briefly describe an upcoming situation in which they predict they’ll feel anxious. Then ask them to imagine the situation as if it’s happening now and visualize themselves using the five steps. SUMMARY Mindfulness is maintaining your attention on your immediate experience while being open, accepting, and curious. Research shows that mindfulness can make treatment more effective, especially when clients are engaged in rumination, worry, obsessive thinking, continual self-­criticism, or avoidance of internal experiences. Integrating mindfulness into therapy is likely to be more effective than teaching it as a standalone technique. Encourage clients to practice mindfulness daily, using formal and informal strategies. REFLECTION QUES TION In what ways could adopting a mindfulness practice be helpful to you? PRACTICE EXERCISES Do a formal mindfulness practice exercise yourself. Read the mindfulness script from earlier in this chapter into a recording device or an app on your phone. Then find a quiet space and get comfortable. You can sit on the floor Cognitive Behavior Therapy: Basics and Beyond

or in a chair, lie down, or stand in one spot. Close your eyes (unless you’d prefer to keep them open). If you worry or ruminate too much, if you criticize yourself, if you try to avoid internal experiences such as negative emotion or negative thoughts, or if you’re experiencing pain or craving, then try to reproduce the thought process or uncomfortable internal experience. (If you don’t have one of those problems, then you can just start the mindfulness exercise.) As you listen to the recording, remember that it’s normal to have your attention wander. Don’t criticize or judge yourself. Just bring your attention back to your breath whenever you notice your mind has wandered. See how you feel after the meditation as compared to before. Also, take 5 minutes now to do an informal practice. Look out the window or at a painting or take a walk (or engage in another activity). Use your senses to become fully aware, accepting, open, and curious about the experience. Every time your mind wanders, avoid criticizing yourself, and gently bring your focus back to the experience.

Integrating Mindfulness into CBT