Ronald Siegel on Integrating Mindfulness into Psychotherapy

Ronald Siegel on Integrating Mindfulness into Psychotherapy

by Deb Kory

Mindfulness expert and psychotherapist, Ronald D. Siegel, shares his insights about how—and when—to integrate mindfulness practices into psychotherapy.
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Mindfulness is an Attitude Toward Experience

Deb Kory: Ronald Siegel, you’re an assistant professor of psychology at Harvard Medical School, a longtime student and teacher of mindfulness meditation, on the faculty of the Institute for Psychotherapy and Meditation and in private practice as a psychotherapist. You’ve done a great deal of work in bringing mindfulness to chronic pain patients and co-wrote a book called Back Sense: A Revolutionary Approach to Halting the Cycle of Chronic Back Pain as well as one for therapists, Sitting Together: Essential Skills for Mindfulness-based Psychotherapy. Most exciting of all—for us at least—you are the star of a new video we produced and are releasing this month called Integrating Mindfulness into Counseling and Psychotherapy, which features you doing mindfulness-based psychotherapy with real clients. In it, you go into great detail about the theory and practice of mindfulness-based psychotherapy, and also do four different therapy sessions with clients each presenting different issues. For our readers who haven’t yet had a chance to watch it, let’s start with the basics: What is mindfulness?
Ronald D. Siegel:
Mindfulness is an attitude toward experience—approaching any moment of our lives with both awareness and acceptance.
Mindfulness is an attitude toward experience—approaching any moment of our lives with both awareness and acceptance. Many people mistake mindfulness for mindfulness meditation, which is actually an umbrella term for many different practices that are designed to cultivate mindfulness, some of which involve following an object of awareness, like the breath, others of which involve things like loving kindness practice or equanimity practices. Those are practices designed to cultivate mindfulness, but mindfulness itself is an attitude toward moment-to-moment experience.
DK: Is it possible to practice mindfulness without having some experience with meditation?
RS: Absolutely. We all have moments in which we’re mindful, in which our minds and bodies show up for an experience. In fact, you might take a minute just now, while reading this, to think of a meaningful moment you’ve had. People will often say, the birth of a child or a graduation or getting married or a particular sunset or a conversation with a friend—all of those moments are essentially moments in which our attention is in the present. We’re accepting of what’s happening and we’re not lost in fantasies of the past that we call memories, nor fantasies of the future. We’re actually present.

We have many moments of this kind of mindful presence in the course of our lives, it’s just that once we start to be attentive to various states of consciousness, we notice that they’re the exception, rather than the rule. They’re relatively rare. So we do mindfulness practices to cultivate more of these moments in our lives.
DK: A sunset or being with a loved one—those are positive experiences. Do we tend to be more mindful in positive moments?
RS: I think instinctually we are, because when we’re experiencing painful moments, we recoil from them. We try to change them or get them to stop, and it takes some practice to open to unpleasant experiences as well. That is a central part of mindfulness practices, particularly in the therapeutic arena, where we understand one aspect of psychopathology as a tendency to resist experience, to try to make it stop.
DK: You are considered a mindfulness expert of sorts and you’re also a psychologist. Have you always brought mindfulness into your psychotherapy practice?
RS: Well, I’d like to challenge that designation first. I’m certainly not a poster child for the practice, given my experience with my own unruly mind. However, I first started practicing mindfulness back in high school, so I have been at it for some time and the principles associated with mindfulness have always infused my psychotherapy practice. In fact, when I learned more conventional psychotherapeutic techniques like cognitive behavior therapy, psychodynamic techniques, systems techniques, humanistic psychological techniques, it was always against the backdrop of Buddhist psychology, which is really the ground out of which mindfulness practices grew.
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Our Relentless Tendency Toward "Selfing"

DK: How do therapists actually bring mindfulness into therapy?
RS:
Experienced psychotherapists are perfectly capable of having a full session, making reflective comments, insightful interpretations, all while planning a 12-course meal and having our attention quite divided.
Mindfulness can infuse psychotherapy on many different levels. It can infuse psychotherapy simply on the level of the practicing psychotherapist—what happens to us as the tool or instrument of treatment when we start practicing ourselves. For example, we start to actually show up in the room more fully. Experienced psychotherapists are perfectly capable of having a full session, making reflective comments, insightful interpretations, all while planning a 12-course meal and having our attention quite divided.
DK: Shhhh, that’s supposed to be a secret!
RS: Yeah, don’t tell people outside of the field! But the more we practice mindfulness, the more we’re able to be present. The other thing that happens is our capacity to be with and bear difficult emotions increases a great deal as we take up these practices. As therapists, we tend to hear about painful matters all day long, and sometimes it feels like too much, so we start to shut down our feelings; that can get in the way of being present. Mindfulness practices can help us to remain open in a fresh way to those painful feelings.

At the next level, there’s what we might call mindfulness-informed psychotherapy, which involves gaining insights into how the mind creates suffering for itself—through our own mindfulness practice and through the experience of longtime practitioners. As we gain some of those insights, we start to see certain patterns of mind that begin to inform our models of psychotherapy. For example, our relentless tendency toward “selfing”— creating narratives in our minds, starring me. These narratives are often quite distorted and create a tremendous amount of tension and suffering as we try to hold on to one self image and abort another.

As we see this through our own mindfulness practice, we start to notice that our clients or patients seem to be struggling with the same thing and we can help them with that by drawing upon our own insights and practices. Similarly, noticing the tendency to resist experience and how that multiplies difficulty. In psychotherapy, regardless of what sort of treatment we’re doing, we try to help people move toward, rather than away from, painful experience. To be more present, rather than to be lost in the thought stream involving narratives about the past and the future. That’s a mindfulness-informed psychotherapy.

Finally, there’s the option that comes out of our own experience of doing meditation and realizing that it helps us be more present, clear, have greater affect tolerance, more perspective, and more wisdom in on our lives, as well as more compassion for others. We think, “Hmm, maybe this could help my clients or patients to do this same. Perhaps I’ll teach it to some of them.” I should underscore that it’s about teaching it to some of them and having a map or an understanding of what sort of people might respond well to which sorts of mindfulness practices, at what stages in treatment or stages in life development. It’s not a one-size-fits-all practice.
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When Mindfulness is Contraindicated

DK: Isn’t it actually contraindicated for some people?
RS: It’s absolutely contraindicated for many people. For example, for folks who have a lot of unresolved trauma, meaning they’ve experienced painful events in their lives that were too difficult to fully let into awareness at the time, so some aspect of them has been blocked. Maybe it’s the narrative historical memory of the event that’s blocked, maybe it’s the affect associated with the experience that’s blocked, but in some way, the experience has been disavowed. Folks like that, if they start doing certain mindfulness practices, such as spending time following the breath, tend to become quite overwhelmed with the rush of previously blocked material that comes into awareness.

The most problematic adverse effect is due to “derepression,” or the rushing into awareness of things which defensively have been held out of awareness.
A colleague of mine at Brown University named Willoughby Britain is doing a large study on the adverse effects of mindfulness practices, and the most problematic adverse effect is due to what she calls “derepression,” which is this rushing into awareness of things which defensively have been held out of awareness up until the start of mindfulness practices. So, much as we wouldn’t in psychotherapy start talking about material in a vivid way that someone’s not ready to talk about, we don’t want to start doing mindfulness practices that might be premature for various people.
DK: Is Britton against using mindfulness at all in psychotherapy?
RS: No, she’s a mindfulness practitioner herself, a research psychologist who is very enthusiastic about these things and is trying to map this territory. What many meditation teachers know from observation is that these adverse effects are much more likely when somebody attends an intensive silent retreat over the course of many days. But I’ve lead countless groups of psychotherapists through mindfulness practices that are as short as 20-30 minutes and it’s not unusual for one or two members of the group to become overwhelmed by the experience, either by the emotions that comes up or by bodily sensations that they tend to keep out of awareness with constant activity and entertainment. Many, many people are vulnerable to reconnecting with split-off contents.
DK: Let’s say someone comes in to see you for psychotherapy and they haven’t done much psychotherapy and they seem somewhat fragile in this way. How might you work with them?
RS: What’s interesting is there are many mindfulness practices that actually help to create a sense of safety, that create a sense of holding, as Winnicott would say. There are mindfulness practices that are akin to guided imagery or have aspects that feel like hypnosis, and if they’re done in the context of a trusting therapeutic relationship, bring the safety of the therapeutic alliance into the experience of the mindfulness practice.

There are also practices that ground us in the safe aspects of moment-to-moment experience. Walking meditation, where we’re feeling the sensations of the feet touching the ground, or listening meditation, where we’re listening to the sounds of nature or the ambient sounds in the city. Or nature meditation, where we’re looking at clouds and trees and sky. Those objects, since they tend to be safe for most people and bring our awareness away from the core of the body—away from where we tend to identify emotion as happening and toward a safe outer environment—can be very stabilizing. In fact, many of those practices are conventionally in trauma treatment called “grounding” practices because they create safety.
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A Transtheoretical Mechanism

DK: It seems to me like everybody in our profession is talking about mindfulness these days. And approaches that I would assume are kind of strange bedfellows—CBT and mindfulness, psychoanalysis and mindfulness—are being paired together. If you go to Psychology Today and look at the profiles of psychotherapists, mindfulness is now a little bullet-point you can select as an orientation. I often wonder if most practitioners actually know what they’re talking about when they claim to work within a mindfulness framework. Like, are they saying that because they’ve been to a one-day meditation retreat or are they actually genuinely skilled in this approach?
RS: Well, I think it’s the same as with any psychotherapeutic model, theory or treatment system—people have very variable levels of understanding of what they’re doing. There are some people who have a great deal of wisdom, compassion and knowledge, who are saying that they’re doing mindfulness-oriented treatments, and there are other people who have a much more cursory exposure to it and may not have much depth of personal experience, but are intrigued by the idea or see it as a useful concept to identify with because other people may be interested in it and looking for a therapist who has some expertise.

But I do think that the field is still in its infancy in terms of really understanding the psychological, as well as the neurobiological, effects of these practices.
The field is still in its infancy in terms of really understanding the psychological, as well as the neurobiological, effects of these practices.
It’s quite a complex field, with many different practices, each one affecting the mind, the brain and the body in different ways and in different ways for different individuals. So while we can make some generalizations and have some guidelines, I think clinicians are best served to see it as very complex.

To the other point that you made about various forms of treatment being incongruent with mindfulness, I actually don’t think most are. I think of mindfulness as a transtheoretical mechanism that is operating in virtually any effective psychotherapy, because virtually any effective psychotherapy is going to help people step out of irrational, unhelpful cognitive patterns. Virtually any effective psychotherapy is going to help people connect with, feel and embrace an increasingly wide range of emotions. Virtually any psychotherapy is going to try to help people to engage more fully moment-to-moment in their lives. Since these are cardinal features of mindfulness practice, you can see them as being helpful in virtually any form of treatment.
DK: So you don’t see it as its own model or approach, but more an attitude and set of practices that are brought into all approaches.
RS: Very much so. While we might choose to actually teach a mindfulness practice to a given client or a patient in a given psychotherapy, that could be done within the context of a cognitive behavioral treatment, a systemic treatment, a humanistic treatment, a psychodynamic treatment and many others as well.

When graduate students come to me and say, “I want to get trained as a mindfulness therapist. Where should I go to school? What kind of training should I have?” I tend to implore them, “Please don’t get trained as a mindfulness therapist. Please get trained as a therapist, first and foremost. Have some understanding of the complexities of the human mind and body, some understanding of the myriad forms of psychopathology that we can get stuck in, a good introspective understanding of your own issues and conflicts and how they get in the way of relating to other people, and get supervision from people who’ve been working with troubled folks for a long time; once you develop that foundation, then integrate mindfulness practices into psychotherapy.”
When graduate students come to me and say, “I want to get trained as a mindfulness therapist. Where should I go to school? What kind of training should I have?” I tend to implore them, “Please don’t get trained as a mindfulness therapist.”


Of course it’s very valuable all along in your training to be doing your own mindfulness practice, to maybe even have a meditation teacher that you turn to for advice. Extremely useful. But if I had a friend who was struggling psychologically and I had the choice of either sending them to a brilliant mindfulness practitioner with very limited clinical training or a reasonably good clinician with reasonably good training as a clinician, but who’d never heard of mindfulness, I would send that person to the clinician in a heartbeat.
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We Are Hardwired for Misery

DK: That’s an interesting point. I live in the Bay Area, and there are a lot of people who are really into Buddhism and mindfulness practices, who kind of eschew psychotherapy for more spiritual practices of meditation and yoga. But at the same time, I know that the Buddhist teachers around here are often imploring people to get therapy, to not do the “spiritual bypass” thing and avoid the work of getting into the muck of our psyches and how they impact our relationships and lives.
RS: Yes, absolutely. Jack Kornfield, who teaches at Spirit Rock in the Bay Area and has written many books on the subject of integrating psychology and Buddhism, recently wrote an article about highly experienced mindfulness meditation teachers, Buddhist teachers, who needed to go into psychotherapy. Ultimately, it’s not that one is better than the other—they are both pathways toward sanity. There are so many pathways to insanity that we actually need a variety of tools to work toward sanity.

I would argue that our natural evolutionarily determined predilection is to be quite nuts and quite miserable.
I would argue that our natural evolutionarily determined predilection is to be quite nuts and quite miserable. As Rick Hanson, who wrote Buddha’s Brain: The Practical Neuroscience of Happiness, Love & Wisdom, puts it, “Our brains are like velcro for bad experiences and teflon for good ones.” It’s a total setup for human misery, not to mention the hardwired tendency toward self-preservation that makes us concerned with how we rank compared to the other primates in our troop, which results in endless self-esteem concerns.

We are hardwired for misery. It is a good thing that we have both Western psychotherapeutic techniques that can help us untangle our narratives and get in touch with our feelings and do that in a healing, interpersonal context, and also have access to mindfulness and compassion practices that can help us transcend our personal story to see existential reality, to face the reality of change and death, to face the reality of sickness and old age, and develop sanity through those practices as well.
DK: As mindfulness practices are becoming more mainstream in the psychotherapy community and the medical community, it’s also becoming more secularized. People might go to their primary care physician and be prescribed a mindfulness-based stress reduction (MBSR) class for high blood pressure, and never even hear the word “Buddhism.” Is there a downside to that?
RS: Let me talk about the upside first and then the downside. The Dalai Lama was talking to a group of clinicians and researchers at Emory University about depression, and toward the end of the conference, I remember being quite moved when he said, “If you folks discover that some elements of Buddhist meditation practices are useful for alleviating depression, I really have only one request for you: please, please don’t tell people that it comes from Buddhism. My tradition is about alleviating suffering, and if you tell people that these are Buddhist practices, you’re going to miss huge numbers of people whose suffering could be alleviated. Don’t get hung up on that. Express this in whatever form is going to be useful in alleviating suffering.”

So my inclination is to tailor our psychotherapy practices to the cultural background, needs, and proclivities of whoever we’re working with. There’s no need to present mindfulness in a way that is going to be alienating. Not only do you not need to mention Buddhism, you don’t need to mention meditation. These practices can be presented simply as attentional control training. When we train our attention differently, we have very different psychological experiences and it helps us both gain insight and cut through all sorts of forms of suffering.

The first rule of psychotherapy is to meet the client or patient where he or she is, and this should not be forced upon people as some alien cultural system, and nor should people be forced to consider the implications of these practices for developing wisdom and compassion if all they’re hoping for at the moment is a little bit less anxiety. That may come later down the road, but we can help them with that anxiety first.

That being said, there are potentials to these practices that are very deep, very wide, and very rich. If a clinician learns mindfulness-based stress reduction and sees these practices primarily as a tool for helping people to relax, they will miss some of the depth and some of the breadth of what these practices can offer. I think it’s useful for clinicians to practice with some intensity themselves, so they can see personally how transformative these practices can be, in a way that goes far, far beyond any benefits that come from relaxation training. It can be very useful for clinicians to learn about Buddhist psychology. It is a very profound and helpful way to understand the mind and how we get caught in suffering.
DK: I think that there’s a lot of mystery and mystification around what mindfulness is, and one of the great things about this new video with you we’re releasing is that we get to see you doing meditation with clients, and modulating it to the specific needs of each client. In real life you don’t do meditation with everyone, but this gives psychotherapists a chance to see what it looks like to bring it into a session.

I think a lot of people are kind of scared to do it and I know that when I first started doing it in my therapy sessions—and I only do it occasionally—I was actually surprised at how profound an experience it was for people and that it had the capacity to stir up some really intense memories. It’s a powerful tool that we have to learn how to use. Can you say a little bit about how you modulate and decide to use meditation in therapy sessions?
RS: First I’d like to pick up on one thing you said.
Many people in our society are involved in states of distraction all day long. Google says we check our cell phone on average 125 times a day.
Many people in our society are involved in states of distraction all day long. Google says we check our cell phone on average 125 times a day. We spend hours watching television. We spend a lot of time chatting with friends. There’s nothing with that—all of these things can have wholesome aspects to them and can make for a rich and interesting life, but for many of us, they keep us from really noticing what’s happening in our minds and in our hearts in each moment. They help to insulate us from the hundreds of micro-traumas that most of us experience just going through the day. The little disappointments, the “I wonder what she meant by that,” the “I didn’t do that as skillfully as I would have,” or “I haven’t quite achieved what I wanted in my life.” Endless, endless reflections, each of which has a bit of pain in it and each of which we want to distract ourselves from with various forms of entertainment and engagement. When people start taking up these practices, all of the pain of those micro-traumas start to come into awareness, and they can indeed be unsettling. Of course they also offer the opportunity to integrate all of that, which is a wonderful potential. So I think we have to be very judicious about it.

My main criteria for whether to actually teach mindfulness practice in a session are twofold; one is, what’s the person’s cultural background and how weird are they going to think it is to choose an object of attention and bring attention to that and return to that object when the mind wanders? Because for some people, it’s like, “forget it, man, that’s not me.”
DK: Yeah, on of the clients in the video, Julia, is a bit like that.
RS: For folks like that, I’m going to be very judicious about it, but one can bring mindfulness into psychotherapy in many, many ways that don’t involve teaching meditation. I already spoke about the shift in our attitude and our capacity for presence as psychotherapists that occurs, as well as the shifts in our models for psychopathology and for what might help people out of psychopathology that might come from our own practice.

Let’s say we’re sitting with somebody and it’s clear that some feeling got triggered. The conventional way to respond to that in therapy is, “What are you feeling now?” A slightly different way to ask the question might be, “what did you notice happening in the body and the mind right now?” That little shift in phrasing starts to shift the conversation from the normal narrative about “my life starring me,” to an observational stance—to what the CBT folks would call “metacognitive awareness,” or what the analysts would call “observing ego.”

To begin to watch and to identify a little bit with awareness itself, rather than the contents of the process. Of course it might be skillful or it might be unskillful in any given moment. For one person at one moment, what they need is to feel your empathic connection to them and saying, “What were you feeling at that moment?” might feel more empathically connected. But for somebody else, they might need to develop some of this observing ego or metacognitive awareness, and if we’re phrasing it in a slightly more objective way, it might serve that purpose. That begins to develop a little bit of mindfulness, even though we’re not doing anything that looks like meditation.

The second criterion I use is, “What’s their capacity to be with their experience?” If they have very little capacity to be with their experience, I want to start with very small doses and very non-threatening contents. If they have more capacity to be with their experience, we can dive into larger doses and get at whatever arises in consciousness right now. It really depends on the person.
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Lighten Up

DK: You mentioned CBT and metacognition and it seems like a lot of what’s happening in mindfulness interventions is “noticing.” In CBT, I tend to think of it more as not just noticing, but blocking or counteracting thoughts. Is there also a methodology within mindfulness training where you’re being more directive with the material that comes up in the brain, or is that off limits?
RS: That’s a very interesting question. Let me correct one thing. There’s noticing, and there’s also feeling in a wholehearted way. I think one mistake people make is they assume that this is a very cognitive kind of endeavor and that’s only one part of it. The other part is really opening to what’s happening on a heart level, in terms of really feeling feelings, as well as noticing what’s happening in the interpersonal field and our relationships and connecting in an alive and juicy way to experience. So I just want to mention that first.

Secondly, CBT folks have described it as the third wave of behavior therapy. The first wave was Skinner on one hand and Pavlov and Watson on the other hand. Operant and classical conditioning and working with modifying behavior. Then came the very important insight that human beings, unlike other laboratory animals, think a lot and our thoughts have tremendous impact on both our emotions and on our behavior. So maybe what we should be doing is using behavioral principles, learning theory, to modify thoughts.

The third wave is coming from a different direction:
What if we start to see all thought as essentially fluid, suspect, unreliable, and based on emotion?
What if we start to see all thought as essentially fluid, suspect, unreliable, and based on emotion? These acceptance and mindfulness-based approaches are all about lightening up in relation to thought, rather than trying to get rid of the bad and hold onto the good.

In my experience, that can be quite powerful, but it takes a while. It’s a much more subtle and in some ways sophisticated way to work with the mind than just replacing maladaptive irrational thoughts with adaptive rational ones. After all, one person’s adaptive, rational thought, is another person’s insanity. We all may agree about our zip code and whether it’s raining at the moment, but as soon as we get into more complex matters, humans differ a great deal and I think we’d do better to have a more relativistic approach toward different thoughts.
DK: So the third wave basically posits that we are all insane.
RS: Yes, we’re all insane. This is a little bit of a bold summary, but my impression of the last 15 or 20 years of advances in cognitive science is basically the realization that all the processes that we’ve thought of as rational are irrational, that bias, desire, cultural proclivity, those kinds of factors are really what determine how and what we think. The idea that we are rational organisms analyzing data for positive goals—yeah, occasionally, but that’s not mostly how we tick. So if we can lighten up generally in our approach to thinking, I think that’s quite helpful.
DK: That is a perfect place to end. Thank you so much for sharing the insights of your otherwise unruly mind.
RS: It’s been a pleasure.

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Ronald D. SiegelRonald D. Siegel, PsyD, is assistant professor of psychology at Harvard Medical School, where he has taught for over 30 years. He is a long-time student of mindfulness meditation and serves on the board of directors and faculty of The Institute for Meditation and Psychotherapy.

He is the coauthor of Back Sense: A Revolutionary Approach to Halting the Cycle of Chronic Back Pain, which integrates Western and Eastern approaches for treating chronic back pain, coeditor of the acclaimed books for professionals, Mindfulness and Psychotherapy and Wisdom and Compassion in Psychotherapy: Deepening Mindfulness in Clinical Practice, and coauthor of the new professional text, Sitting Together: Essential Skills for Mindfulness-based Psychotherapy.

Siegel lives with his wife in Lincoln. He regularly uses the practices in this book to work with his own busy, unruly mind.
Deb Kory, PsyD, is the content manager at psychotherapy.net.  She received her doctorate in clinical psychology from the Wright Institute and has a part-time private practice in Berkeley, CA. She loves both of her jobs and feels lucky to be able to divide her time between therapy, writing and editing. Before deciding to become a psychotherapist, she worked as the managing editor of Tikkun Magazine and published her writings in Tikkun, The Huffington Post and Alternet. Currently, she is working on turning her dissertation, Psychologists: Healers or Instruments of War?, into a book. In it, she describes in great detail the historical context and events that led to psychologists creating the torture program at Guantanamo and other "black sites" during the War on Terror.
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CE credits: 1
Learning objectives:
  • Describe the concept of mindfulness and its application to psychotherapy.
  • Illustrate the different levels of mindfulness that are used by mindfulness-oriented psychotherapists.
  • Learn when mindfulness is contraindicated in psychotherapy.
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