Using Mindfulness Techniques in Counselling
Whether the approach is highly structured or not, and whether the practices are formal or informal, bringing mindfulness into helping roles has several general principles. There are also limitations and contraindications that must be considered before and during any use of mindfulness practice with clients, as well as when clients are supported in developing an independent mindfulness practice.
Many people who come into contact with helping and health care professionals experience issues with emotions or moods of an intensity or duration that is troubling, or which drives functional problems. Mindfulness is often applied as a way of helping clients change their relationships to these thoughts and feelings, and sometimes to triggering events. Developing a ‘decentred’ position is seen as particularly helpful in this process (Follette, Palm, & Rasumssen Hall, 2004). Increasing capacity for emotion regulation, and particularly the attitude of acceptance, is another common theme:
Mindfulness is an important tool in developing emotion regulation skills (Linehan, 1993). […] In other words, individuals can use mindfulness strategies to increase awareness and flexibility of responding to emotional experiences, as well as to practice experiencing thoughts and feelings they typically avoid. Mindfulness exercises provide instructions on how to attend to and identify thoughts, feelings, and memories, without acting to alter those private experiences. They also teach increased awareness of emotional responses and the effectiveness of those responses in the current context. (Follette et al., 2004, p. 199).
Often connected with emotional dysregulation is experiential avoidance: the attempt to (as the name suggests) avoid the experience of particular states or situations. The view that experiential avoidance can create serious problems is at the core of psychopathology as it is conceptualised in acceptance and commitment therapy (ACT): if we are not aware of what we are experiencing, we will limit our capacity to respond adaptively. We will also have difficulty appropriately regulating emotion. Mindful awareness and acceptance, then, are tools for addressing such issues.
Clients may also experience a lack of compassion or acceptance for themselves. Such issues can be addressed by development of these capacities through mindfulness practice (e.g., Follette et al, 2004; Kabat-Zinn, 2013). Kaplan and Chang summarise the benefits they see in their practice:
[W]e have noticed that mindfulness can be clinically useful for patients in five key ways:
- By increasing awareness of some pattern, experience, or issue
- By promoting relaxation
- By cultivating acceptance of some mental or emotional experience
- By developing insight into an unconscious process
- By facilitating the capacity to choose a more effective response (Kaplan & Chang, 2017, p. 64).
Another key commonality is the agreement that only those helping professionals who use mindfulness themselves should integrate it into their work with clients (e.g., Pollak, 2016). Some mindfulness-based interventions (MBIs) require that facilitators have an established practice and formal training in the approach. Other approaches do not necessarily require this, but there is an expectation that the professionals delivering them will engage in some form of regular practice.
Using mindfulness with clients must be done with consideration and purpose. That is, like any other intervention or technique, there should be a good reason for applying it. With the range of benefits for which evidence is growing, there may be several reasons to suggest mindfulness practice to a client, but this needs to be weighed against other interventions. Mindfulness, after all, is just one tool, and no single tool works for all jobs.
For clients seeking stress reduction, for example, mindfulness is only one viable option among many, including relaxation training, cognitive restructuring, exercise, facilitated problem-solving, lifestyle changes, and more. Some interventions will be more or less useful given the client’s personality, experience, preferences, particular issues, and circumstances; whether mindfulness is likely to be helpful needs to be considered in this context. And, as with all interventions, there will be clients for whom mindfulness is not effective. There may also be those for whom it will be effective at some point, but not at this particular time. Finally, there are clients for whom mindfulness is contraindicated.
Limitations of mindfulness
One of the problems with the uncritical promotion of mindfulness, which appears all around us, is the encouragement to practice without considering whether there could be unintended consequences. While the benefits of mindfulness for clients are supported by the anecdotal evidence of many practitioners and an increasing body of research, mindfulness is neither a panacea nor appropriate for everyone. We must pay particular attention to the potential risks and recognise that negative effects of mindfulness are more likely to occur among the groups that commonly seek the support of helping professionals (Baer & Kuyken, 2016).
Introducing Mindfulness Practices in Client Work
It is likely that many of your clients have heard of mindfulness; some have probably tried it and others may even have an active practice. It is not safe, however, to assume understanding of mindfulness, or that clients are aware of the potential risks and contraindications, so clear communication is required when exploring mindfulness exercises as potential interventions.
Given how common misconceptions are, it is useful to start with information about what mindfulness is and is not, and to do some myth-busting with clients. It can also be helpful to talk about mindfulness in a secular way, unless the client has a particular belief system they would like to link the practice to. Informed consent is particularly critical; as keen as any of us individually might be about mindfulness, we have an ethical responsibility to provide accurate and unbiased information to our clients, sufficient that they can make an informed decision about whether to engage in it. This includes being open about other options, the limitations of mindfulness and the research into it, contraindications, and the potential for adverse events.
Whether in structured MBIs or other settings, the use of mindfulness techniques (formal or informal) should start with information. The information given will need to be tailored to the client’s particular situation, but a few examples include:
- For a client experiencing problems relating to stress, discussion could include the ways in which parts of the brain are active when people experience stress, and the use of mindful-ness to reduce stress. A worker sufficiently familiar with the material might talk about the changes in neural activity that have been hinted at in correlational research.
- A client who gets caught up in rumination can be given CBT-style psychoeducation about such ways of thinking and their negative effects. They can then be introduced to the potential for mindfulness to loosen the hold of these thoughts and reduce the impact of rumination.
- A client could be introduced to the differences between reacting and responding or between pain and suffering, as they are understood in this context. The client could then be invited to consider these distinctions, and asked whether they are interested in seeing whether mindful-ness might help increase their capacity to respond, reduce suffering, etc.
Mindfulness is best introduced as one of a range of strategies that could be of use, and which the client can be supported in trying if they choose to do so (provided no contraindications are present). Respecting the client’s autonomy and right to choice is critical, and the risk of putting a client in such a position that they fear disappointing the worker or damaging the relationship by declining to engage needs to be taken into account. A helper who is overly keen or working with a client who has trouble asserting themselves may place clients at risk of agreeing to an intervention that they are not comfortable with, so sensitivity must be used in introducing mindfulness practice. It can be helpful to frame mindfulness exercises as ‘experiments’ (Pollak, 2013), for example, “This is an activity we can try and, if you think it might be useful to you, we can practice it regularly in session. If you give it a go and decide it’s not for you, we’ll try something else.”
Using Mindfulness in Session
How do helping professionals actually use brief mindfulness practices in the context of client work? Again, specifics vary, but it is common to use sensory-based practices to help clients ground in the present, to guide clients through bringing mindful awareness to their thoughts or other aspects of experience that can then be addressed more effectively, and to use mindfulness exercises to help clients relax or de-stress. (Although this last is a philosophically questionable application if it helps clients to reduce arousal, this may be beneficial.) Helping clients bring awareness to aspects of their experience that they are not usually aware of is not without risks, but where safe and appropriate mindfulness practices can help with ‘defusing’ from thoughts, regulating emotion, understanding and altering habitual behaviours and reactions, and more. The use of mindfulness practices may also be part of a skill-training intervention, when clients want to practice in session something they will then use in their day-to-day lives.
For some clients, formal and breath-based practices are overly intense, distressing, or otherwise off-putting, so many practitioners suggest using informal and sensory-based activities, at least initially (e.g., Baer & Kuyken, 2016). Clients can also be guided in the use of these outside of the session. Just a few options include:
- The ‘five senses’ or ‘5-4-3-2-1’ type sensory activity, which clients can easily practice independently once learned.
- Carrying an object that they can mindfully hold; being guided through noticing the weight, temperature, and texture in session; and then practicing doing so without guidance.
- A client who likes tea or coffee can have some in session, and be guided through mindfully attending to the process of making it, watching the steam rise, noticing the smell, feeling the temperature of the cup, and taking mindful sips.
The key is to tailor the practice to the person, bringing attitudes of interest and flexibility to your own work, as well as encouraging them in your clients.
Mindfulness is also used in specific areas of client work, such as:
Pain: Some clients with medical conditions learn to pay mindful attention to their experience as part of pain management (this was Kabat-Zinn’s original intention with MBSR, after all).
Medical conditions: Mindfulness is being trialled to address various mental health impacts of serious – either acute or chronic – physical health problems (e.g., Cillessen, Johannsen, Speckens, & Zachariae, 2019). More recently explorations in this area include the encouragement of mind-ful eating in some diabetes and weight management programs (e.g., Medina et al., 2017).
Addiction: Mindfulness is integrated via ‘urge surfing’ in some alcohol and other drug (AOD) programs. Urges to use substances (or engage in other compulsive or addictive behaviours) are seen as temporary aspects of experience. In urge surfing, mindful attention and the attitude of acceptance are brought to such urges (Harris, Stewart, & Stanton, 2016). Attention can be paid to the breath, sensations, thoughts, and so on, including the sensations of the urge. The client might visualise the urge as a wave that comes and goes, and use “their breath as a surfboard to successfully ride out the wave” (p. 145). This approach also has the benefit of removing the negative consequences of attempts at avoidance.
Stress and anxiety: Mindfulness is being used to help people manage and reduce chronic stress and anxiety. Much of the research in this area focuses on specific MBIs, rather than informal practice, but there are growing indications that even brief practices could be useful.
Obesity: Mindful eating is being used to help alter attitudes and behaviours associated with eating (Black, 2019).
Promoting change: There is also anecdotal and increasing research support for the use of mind-fulness to support positive change in a wide range of areas, from its use as a general coping skill or self-care strategy, to improving focus and performance, and to enhancing relationships.
Helping Clients Develop their own Mindfulness Practices
When clients want to use mindfulness practices beyond sessions, there are considerations relating to safety and contraindications that need to be taken into account. Excluding cases where these apply, however, many clients may be effectively supported to use mindfulness practices outside of session. Attending mindfulness classes with experienced teachers is ideal, of course, but this will not be desired by some and is inaccessible to many. If clients want to build their personal mindfulness practice, they can start using the practices learned in session independently, much the way they might with other skills learned in this context. They might then solely use the practices they have learned in this context, or be supported to find other useful resources to support practice, including guided audio tracks, written descriptions of exercises, books and articles, and mindfulness apps, many of which are freely available online or from libraries.
This can, but does not need to, involve formal practice. Setting up a formal or regular practice can be encouraged using the strategies to support habit formation that you are already familiar with as a helping professional. For other clients, finding ways to integrate informal practices into their day-to-day life will be more helpful. The ways this can be done are many and varied, such as making a cup of tea mindfully in the morning, eating mindfully, doing housework mindfully, or other ‘mindful activities’. Clients may also simply ‘tune in’ to their thoughts, breath, posture, or other aspects of experience at various points through the day, or in certain situations.
Editor’s Note: This article is an excerpt from Unit 3 – Mindfulness in the Helping Professions in AIPC’s Certificate in Mindfulness Practice (CIMP). We also have an upcoming Upskill course in Mindfulness in Therapy.
- Baer, R., & Kuyken, W. (2016). Is mindfulness safe? Retrieved February 2, 2020, from website.
- Black, M. (2019). Mindful eating for weight loss: Try before you buy. Journal of Clinical Endocrinology and Metabolism, 104(3), https://doi.org/10.1210/jc.2018-02551
- Cillessen, L., Johannsen, M., Speckens, A. E. M., & Zachariae, R. (2019). Mindfulness-based interventions for psychological and physical health outcomes in cancer patients and survivors: A systematic review and meta-analysis of randomized controlled trials. Psycho-Oncology, 28(12), 2257-2269. https://doi.org/10.1002/pon.5214
- Follette, V. M., Palm, K. M., & Rasmussen Hall, M. L. (2004). Acceptance, mindfulness and trauma. In S. C. Hayes, V. M. Follette, & M. M. Linehan (Eds.), Mindfulness and acceptance: Expanding the cognitive-behavioural tradition, (pp. 192-208), New York, NY: Guilford Press.
- Harris, J. S., Stewart, D. G., Stanton, B. C. (2017). Urge surfing as aftercare in adolescent alcohol use: A randomized control trial. Mindfulness, 8(1), 144-149. https://doi.org/10.1007/s12671-016-0588-7
- Kabat-Zinn, J. (2013). Full catastrophe living. How to cope with stress, pain and illness using mindfulness meditation (2nd ed.). London, UK: Piatkus.
- Kaplan, J., & Chang, D. F. (2017). Mindfulness in practice: Incorporating mindfulness inside and outside of sessions. In E. Zerbo, A. Schlechter, S. Desai, & P. Levousnis (Eds.), Becoming mindful: Inte-grating mindfulness into your psychiatric practice (pp. 61-78). Arlington, VA: American Psychiatric Association Publishing.
- Medina, W. L., Wilson, D., de Salvo, V., Vannucchi, B., de Souza, E. L., Lucena, L., Sarto, H. M., Garcia-Campayo, J., & Demarzo, M. (2017). Effects of mindfulness on diabetes mellitus: Rationale and overview. Current Diabetes Reviews, 13(2), 141-147. https://doi.org/10.2174/1573399812666160607074817
- Pollak, S. M. (2013). Teaching mindfulness in therapy. In C. K. Germer, R. D. Siegel, & P. R. Fulton (Eds.), Mindfulness and psychotherapy (2nd ed.), 133-147. New York, NY: Guilford Press.