In 1979, Jon Kabat-Zinn, author and professor emeritus of medicine at the University of Massachusetts Medical School, founded the Mindfulness-Based Stress Reduction Clinic, which uses a combination of mindfulness meditation and yoga to promote healing. In the ensuing decades, interest in mindfulness — not just for physical healing but also for emotional healing — has mushroomed. In a reader poll taken at CT Online (ct.counseling.org) in November, 87 percent of respondents said that they regularly use mindfulness techniques with their clients.

Meditation is perhaps the best-known mindfulness-based practice, but there are actually numerous techniques, says national certified counselor Danielle Richards. Her research, which she has presented at American Counseling Association conferences, focuses on mindfulness and self-compassion.

“There are clients and clinicians who benefit most from guided imagery and contemplative practices, while for others what is most helpful is sitting and walking meditation,” Richards says. “One individual may benefit from brisk walking meditation, while another from slow. Another individual may find that chanting or utilizing a mantra anchors them, while another the breath.”

At root, mindfulness is simply the practice of being present in daily life, explains Richards, an instructor in psychology and mental health/developmental disabilities at the College of Southern Nevada. “It encompasses being present with those around you and with what you are doing,” she says. “Overall, what I have seen as most helpful, across settings and populations, are practices that help individuals bring mindfulness into their daily lives.”

Walking meditation is one of the activities Richards recommends for cultivating awareness. “It can be applied to normal activities one does in a day, such as opening a door or walking between classes or brushing one’s teeth or washing clothing,” she says.

Richards teaches two types of walking meditation. “One involves lifting, moving, placing … where the individual focuses on being mindful of each aspect of the movement as they perform it slowly,” she explains. “The other type involves counting while walking at a comfortable pace, so it can happen as part of daily activity rather than as an isolated formal practice. It involves a sequence such as 1, 1-2, 1-2-3, 1-2-3-4, and goes up to 10. The counting serves as a placeholder for the present moment — just as the breath does in sitting meditation — so that as one’s mind wanders, the counting allows [the person] to come back to the present moment.”

Richards, a former counselor practitioner who presents workshops on mindfulness and mindfulness meditation, recommends that clients try out different walking paces to see which works best for them.

“Notice Five Things” is another simple method that counselors can use with clients to help them tune in to their surroundings, Richards says. The steps are as follows:

1) Pause for a moment.

2) Look around and notice five things that you can see.

3) Listen carefully and notice five things that you can hear.

4) Notice five things that you can feel in contact with your body.

Noting or describing — silently putting words to experience — is a technique that can be incorporated into any mindfulness practice, but it is particularly helpful for those who ruminate or are simply stuck in their own heads, Richards says.

“For instance, when feelings arise, one can silently note those feelings,” she says. “[You] could use a phrase like, ‘It’s a feeling,’ or be much more specific and note each individual feeling by name: anger, boredom, calm. For example, in a tense situation, one might observe a feeling of anxiety and simply note it as ‘I’m feeling anxious’ or ‘I’m noticing a feeling of anxiety.’”

This kind of mental noting of emotions helps clients to identify feelings and thoughts that they want to resist and instead learn to accept them through methods such as breathing exercises. “For example,” Richards says, “‘Breathing in, I am feeling worried. Breathing out, I am taking care of my worry.’”

Awareness is central to mindfulness practices. Richards explains that becoming truly aware of what is distressing to an individual and how that stress affects him or her is a key part of stress management.

As part of becoming aware of emotions, and stressful feelings in particular, Richards likes to use journaling with clients. “Individuals can become truly aware of the stress in their life and how they engage with it. This is a first step to choosing a response rather than acting on gut reaction,” she says.

“We all have unique patterns of how we respond when we are distressed and a unique set of stressors,” Richards explains. She encourages counselors to have their clients discuss or journal on the following questions:

• When you feel stressed out, how does the stress manifest in you? Do you experience it physiologically — tightness in your throat, rapid heartbeat, sweating? Behaviorally — crying, yelling? Emotionally — sadness, depression, anger? Cognitively — negative thinking patterns? Or some combination?
• Notice how much time out of the day you feel out of control, overwhelmed and stressed. Where have your thoughts taken you? The past, present or future? What are your experiences with past, present and future thinking?

Richards is also a big proponent of mindfulness meditation but notes that it is sometimes a misunderstood practice. “Many people think that mindfulness is a practice that involves emptying one’s mind of thoughts. This misconception can leave people feeling like poor meditators,” she says. “Mindfulness meditation is not about emptying the mind, but rather focusing one’s attention and training one’s mind to be more focused, effective and skillful in everyday life. Mindfulness is not about trying to make anything happen or getting to some special state of relaxation, although relaxation may be a byproduct.”

“When teaching formal sitting meditation,” Richards continues, “I stress that when one’s mind wanders, one gently brings it back to the breath, which is representative of the present moment.” In fact, she adds, noticing that the mind has wandered and then bringing it back to the present moment is itself a sign that the person has accomplished mindfulness.

Mindfulness for college students

Richards has also conducted a series of research studies with undergraduate students to determine whether brief mindfulness interventions affect measures of well-being and have the potential to increase self-compassion and decrease thought suppression. The most recent study, consisting of three stages over a period of roughly two weeks, combined group instruction and individual activities.

In the first stage, 15 students participated in a five-hour group meeting during which mindfulness was defined for them and they received instruction on how to practice sitting mindfulness. The group also engaged in a guided sitting mindfulness exercise together. Participants then learned about and engaged in several types of walking mindfulness exercises, followed by a mindful eating activity. In addition, the students were taught about stress, stress reduction and how mindfulness could help them become more aware of the relationship between thoughts, feelings and behaviors.

The participants also learned about lovingkindness mediation, which works by extending lovingkindness to oneself, to a person one loves and cares about and then to a person who is challenging to love, in that order. The actual meditation involves silently repeating the phrases, “May I be happy, may I be healthy, may I be safe and may I have the ease of well-being.” Individuals then say these phrases again, replacing “I” with the name of the person they love and care about and then with the name of the person who is challenging to love.

In the study’s second stage, participants were tasked with performing different mindfulness activities on their own over the course of two weeks and completing the online diary that kept a daily record of these activities. Every other day, the students received online “booster” activities that assisted them in their independent mindfulness practices. For example, for the lovingkindness meditation, the booster treatment consisted of answering the following questions: What arose in your mind as you practiced lovingkindness for yourself? Describe the images or feelings that came up. What are the easiest and most difficult aspects of this practice? What was your experience in working with a difficult person?

When participants submitted documentation of having completed the booster activity through related homework assignments, they also submitted their online diaries. The instructor provided individualized feedback to each participant through email.

The third stage consisted of another five-hour group session that included conflict-resolution activities and explored incorporating formal mindfulness practices into daily living.

The study showed that the mindfulness program was effective for increasing wellness and self-compassion and decreasing thought suppression, according to Richards. This is particularly significant, she says, because college counseling centers are typically short on both time and money, making brief treatment methods particularly attractive.

ACA member Tamara Knapp-Grosz, director of the counseling and testing center at the University of North Texas, has also found mindfulness practices useful for helping college students. “Students transitioning to college are inundated with so many changes that they may feel a true sensory overload at times, which can translate to a ‘freeze’ stress reaction where they shut down,” she says. “Mindfulness practices teach students how to slow down and give time to pause and observe rather than feeling the pressure to react immediately. I typically will do lots of psychoeducation on how strategies can be utilized and have homework between sessions where students can try out or practice what we have discussed in session.”

Knapp-Grosz, president of the American College Counseling Association, a division of ACA, uses a variety of mindfulness strategies with students. Among her favorite activities:

• Mindful hand exercise. Hold your hands together tightly for 10 seconds and release. Pay attention to the sensations of tension and release.
• Mindful writing. Find a favorite place and focus on the sounds, smells and tactile experiences around you. Write these down in as much detail as you can. This helps you to be fully present in the moment rather than racing to the past (depression) or to the future (anxiety).
• Mindful awareness. This is similar to mindful writing, but instead of writing about the things around you, simply slow down and take in every detail in your surrounding area. Look at things as if you are seeing them for the first time.
• Stop and breathe. As your mind wanders, bring yourself back to focusing on your breath.
• Mindful balloon. “When something challenging is bombarding us, using [our] breath can also get us unstuck and [help us] move on rather than ruminating,” Knapp-Grosz says. “I teach students to visualize letting go of whatever challenge they are struggling with and cannot move on from as they exhale each breath. Sometimes even seeing a balloon floating away, with each breath going higher and higher.”

Mindfully managing addiction

ACA member Mark Schwarze finds mindfulness practices a helpful addition to the traditional group format used in addictions counseling. The group format is typically based on techniques rooted in cognitive behavior therapy (CBT) and motivational interviewing.

“From a biopsychosocial model, those with innate vulnerabilities to addiction have high levels of anticipatory thinking and reactivity,” explains Schwarze, an assistant professor and director of the clinical mental health program at Appalachian State University in North Carolina. “Mindfulness can be a way of ‘being’ in the world that, at first, feels difficult. Over time and with practice, the mindful client can develop a passive response to triggers and leave more time to make choices that will lead away from impulsive behavior. In traditional CBT-based relapse prevention, clients are required to dispute an illogical/irrational or impulsive thought and replace it with a more logical/rational one. Mindfulness-based relapse prevention only asks for acknowledgment and [a] return to the present.”

Schwarze, who presented at the ACA 2016 Conference & Expo in Montréal on mindfulness in addictions counseling, describes three specific exercises counselors can use with these clients: basic breathing meditation, a SOBER breathing space exercise and the practice of urge surfing.

“[Breathing] meditation typically focuses the client on their breath with instruction to acknowledge distractions without judgment, and then to return focus to the breath,” Schwarze says. “It is the ability to be aware of your mindlessness and return focus to the present that is really the skill to be developed.” He adds that counselors can find many examples of breathing meditation scripts or prerecorded guided meditations to help clients learn this type of meditation.

Schwarze says the other two techniques he favors are borrowed from mindfulness-based relapse prevention therapy. “The SOBER breathing space is designed to be a short exercise to break stimulus-response patterns that can happen in high-risk times for recovering clients,” he explains. During these times, clients are taught to take a three- to five-minute timeout and follow the prompts in the acronym SOBER:

S: Stop what you are doing and focus.

O: Observe the sensations in your body.

B: Breathe and focus on your breath.

E: Expand your awareness.

R: Respond mindfully.

The other technique, urge surfing, teaches clients struggling with addiction to see their cravings in a different way, Schwarze says. “Often we think of cravings as increasing in intensity over time when, actually, cravings crest and trough like a wave. At the crest of the urge, clients are asked to observe without judgment. The client observes what is happening at that point and time and doesn’t place values on those thoughts as good or bad. Alternately,” he says, “the bottom of the craving holds equally important information that may help clients root themselves in this less-anxiety-inducing space.”

Schwarze points out that clients can download recordings to guide them through both the SOBER breathing space and urge surfing exercises. “Having recordings can be a great way to encourage clients to engage in mindfulness practice on a daily basis,” he says.

Schwarze is a firm believer in the benefits that learning to live mindfully can have for clients struggling with addiction and substance abuse problems. “I suggest that counselors work with their clients to develop a realistic plan for mindfulness practice. Daily practice is ideal, but counselors should see what clients are willing to do,” he says. “Technology has made practice much easier. There are multiple apps, websites, recordings and videos that provide clients with guided meditations and other mindfulness-based exercises. Some techniques might be helpful during a craving or other difficult time but, really, developing an orientation to the experience of mindfulness provides a wider benefit.”

A source of counselor clarity

Of course, mindfulness isn’t reserved solely for clients. Counselors can benefit too, both personally and professionally.

In his pursuit of a greater overall sense of wellness, counselor Jeffery Cochran began seeing an acupuncturist in his late 30s. After doing a holistic evaluation of Cochran, the acupuncturist told him, “You need to spend some time just sitting and staring.”

“I realized that I was never still, or at least never inactive, internally or externally,” says Cochran, a professor of counseling at the University of Tennessee. “I had been highly successful being goal directed, but maybe that driven approach to life was beginning to have its limits, and [I] was not fully who I wanted to be. So, I embraced meditation to learn to be still, to learn to quiet my mind, to learn to react to fewer impulses.”

“I look at my meditation time as a counterbalance to my fairly driven, goal-oriented personality,” says Cochran, who presented on meditation and counselor self-awareness and well-being at the 2016 ACA Conference. “It is time set aside each day in which my intent is to be without tasks to check off. Time to simply ‘sit and stare’ while bringing my focus only on a meditation that I have selected [such as] breath counting or watching thoughts. I try to have the mindset that if there is some positive outcome, that’s nice, but whether there is any positive outcome or not, my purpose is served in taking some time to focus the mind away from my work tasks, away from my impulses and racing thoughts — time to just sit with myself.”

Cochran emphasizes that he does not consider himself an expert on mindfulness, but he believes that his personal practice has given him a better sense of balance in his life and also made him a better counselor. He wrote about meditation exercises in the second edition of The Heart of Counseling: Counseling Skills Through Therapeutic Relationships, a book that he co-authored with his wife, Nancy.

“Sitting with one’s own emotions [and] listening to one’s own thoughts without judgment is great training for attending to the emotions and thoughts of another without judgment,” Cochran explains. “Meditation is also about acceptance — learning to accept experience, learning to accept self. I think that sometimes our lack of acceptance of aspects of others stems from areas of the self that are
not accepted.”

Since beginning a regular practice of mindful meditation about 15 years ago, Cochran has noticed other differences in his counseling too. He says he is more at ease with the silences that are a natural part of counseling and better able to sit with the most painful and intense emotions.

“Meditation can help the counselor share the client’s experience as needed without defenses or hesitation, but with a steady awareness of one’s self as separate,” Cochran explains. “Any negative influence from the counselor’s unspoken or unrealized agenda or bias is decreased as the counselor comes to the session with a greater awareness of self, making clearer [those] choices of how best to help and what responses to provide.”

Knapp-Grosz also believes that mindful practices can be a boon to counselors. “We are all super busy as counselors and are managing multiple stressors. Learning simple mindfulness techniques that we can use between sessions or following a stressful meeting helps us with rebounding and, in turn, being more fully present for our next [client].”

In addition to using the exercises that she teaches to college students at her counseling center, Knapp-Grosz has another favorite mindfulness technique that she has dubbed “smelly travel.”

“[It’s] one of my all-time favorites that I try to do whenever I travel,” she says. “I really stop and breathe in the smells around me while looking at the beauty before me. Focusing on the smell helps me to imprint the feelings of relaxation and joy of that moment, and I can recall it by using that smell again in the future to stimulate that relaxation and feeling of peace when I need it. For example, I can return to my favorite Hawaiian beach very vividly by smelling Kona coffee. This is the opposite of what happens in PTSD [posttraumatic stress disorder], where a smell elicits the past traumatic memory. Mindful smelling can be used in powerful ways as a stress reliever and is wonderful for anxiety and depression.”

Knapp-Grosz also touts the benefits of mindfulness practices for stimulating creativity. “Sometimes we need to unplug and take a timeout to get our creative juices going again,” she says. “Mindfulness helps us notice things around us that we have shut out. It brings perspective and a new way of viewing all that is around you. Have you ever noticed that some of your best ideas seem to come at that time just before you fall asleep or when you wake up? This is similar in that mindfulness practices quiet all of that day-to-day chatter that keeps us from being aware of all of the innovations around us.”

Counselor, heal thyself

Working with first responders in his Philadelphia-area practice inspired licensed professional counselor Charles Jacob to begin studying vicarious trauma. “For a lot of folks who see terrible things during their 9-to-5 [jobs], it can be incredibly difficult to leave work and go about daily life as if the world is a normal place,” he says. “So many [clients who were first responders] seemed to have a belief in the world that was, well, pretty jaded and hopeless.”

Jacob, an assistant professor in the counseling and family therapy program at La Salle University in Philadelphia, was particularly interested in how working with trauma affects counselors. “Vicarious trauma isn’t unique to counselors, but counselors who work with traumatized populations are certainly more susceptible,” he observes.

The effects of vicarious trauma can cause changes to counselors’ core beliefs about their work, says Jacob, a member of ACA and president of the Pennsylvania Counseling Association. “For example, if I spend the majority of my time working with victims of sexual assault, I may begin to believe that the world is a cruel and unfair place,” he explains. “I may become fixated on the idea that bad things happen to good people so often that the world is a dangerous place, and safety for myself and the people I love is wishful thinking at best. This cynical worldview can lead to depression, anxiety or a general decreased belief in the goodness of humanity. For these folks, the standard self-care prescription doesn’t seem to work as well. In short, a yoga class will not cause me to change my core belief that people are inherently terrible.”

Curious about whether mindfulness might be a useful intervention, Jacob and Rebecca Holczer, a colleague from La Salle, conducted a research study with a group of counselors who worked primarily with trauma survivors. The participants completed two questionnaires, the Trauma Attachment and Belief Scale, which assesses the presence of vicarious traumatization, and the Cognitive and Affective Mindfulness Scale–Revised, which assesses mindfulness qualities. The results, published in the Journal of the Pennsylvania Counseling Association this past spring, indicate that counselors who are naturally more mindful — meaning inherently better at being more present and aware — are less likely to experience vicarious trauma.

“As best we can figure, the combination of awareness and nonjudgment allows [mindful counselors] to empathize with the client without losing their sense of self,” Jacob says. “They care about the problem when they’re in session, but they let it go and move on afterward. They see the problems the client is experiencing more objectively, but no less compassionately.”

Although being mindful is linked with less vicarious trauma, there is no research on particular practices, says Jacob, who is also a licensed psychologist and licensed marriage and family therapist. “We know that mindful people are less susceptible to vicarious trauma, but we’re still trying to make sense of interventions that directly affect the process,” he says.

Research does, however, link meditation and breathing exercises to stress reduction. With that in mind, Jacob and colleagues gave a presentation at the ACA 2016 Conference & Expo that featured mindfulness exercises that counselor practitioners can use to help guard against vicarious trauma.

“In our presentation, we talked about the use of meditation before sessions. The idea here is to reduce the experience of anxiety during the traumatic event [hearing a client’s story that the counselor finds traumatizing] to alter the emotional aspect of the memory of trauma so that it causes less stress later on — similar to the use of beta blockers in the treatment of PTSD.”

“For example,” he explains, “a counselor who meditates for 10 minutes before what they perceive to be a stressful session would hopefully go into the meeting with a reduced heart rate, blood pressure, etc. When presented with a troubling client narrative, there’s a better chance [the counselor] might feel less stress and distress, and have a reduced chance of vicarious trauma, [because] they will remember the event later on as being less stressful.”

The meditation practice requires just 10 minutes at the beginning of the day, Jacob says. He recommends that counselors use a mat on the floor or sit in a chair comfortably, set a timer for 10 minutes and then sit silently and motionless while mentally repeating a personal mantra that syncs with slow, controlled breathing. “Focus only on remaining still, breathing, repeating your mantra and staying focused and present,” Jacob emphasizes.

Jacob and his colleagues also presented a breathing exercise that counselors can use themselves in session. “The basic idea here is that exposure to trauma causes the sympathetic nervous system to kick in,” Jacob explains. “Your heart rate and blood pressure go up and your breathing becomes rapid and shallow. … You can’t control your heart rate, blood pressure or any of those other pesky automatic responses … but you can control your breathing.”

Jacob describes the exercise as a fairly uncomplicated method of slowing down the breathing and holding enough oxygen in the lungs long enough to do good things in the body. “The other plus to this exercise: It’s simple enough for you to do it in front of someone and not look insane,” he says with a laugh.

“In the event that a client begins recounting a trauma that is particularly troublesome for you, first continue focusing on what the client is saying,” Jacob directs. “Then use a slow, controlled breath to inhale through your nostrils until your lungs reach their full capacity — a process that takes about 10 seconds. Hold this breath for approximately one second, and then begin the process of slowly exhaling through a small parting of the lips — no bigger than the diameter of a coffee straw — for the duration of about 20 to 30 seconds. You should notice nothing amazing really … just a slight decrease in heart rate and blood pressure such that the physiological response of anxiety is less and the ability to be aware and present is easier to access.”

Jacob says an additional impetus for his research was his concern that the phrase “self-care” has been getting a little too nebulous in the counseling profession. “We talk about it very generally and very often, but I find that this doesn’t usually provide much direct guidance for struggling clinicians. I really think that making efforts to think and practice differently is our best bet at keeping clinicians safe, healthy and happy.”

 

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Additional resources

To learn more about the topics addressed in this article, take advantage of the following select resources offered by the American Counseling Association:

Journal articles (counseling.org/publications/counseling-journals)

• “Mind The Gaps: Are Conclusions About Mindfulness Entirely Conclusive?” by Adam W. Hanley, Neil Abell, Debra S. Osborn, Alysia D. Roehrig & Angela I. Canto, Journal of Counseling & Development, January 2016
• “Effect of a Mindfulness-Based Intervention on Counselor-Client Attunement” by Stefani A. Schomaker & Richard J. Ricard, Journal of Counseling & Development, October 2015
• “Mindfulness-Based Awareness and Compassion: Predictors of Counselor Empathy and Anxiety” by Cheryl L. Fulton & Craig S. Cashwell, Counselor Education and Supervision, June 2015
• “Mindfulness-Based Interventions in Counseling” by Amanda P. Brown, Andre Marquis & Douglas A. Guiffrida, Journal of Counseling & Development, January 2013

Book (counseling.org/bookstore)

• Integrating Spirituality and Religion Into Counseling: A Guide to Competent Practice, second edition, edited by Craig S. Cashwell & J. Scott Young

 

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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editor: ct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.