Clinical Handbook of Mindfulness (113 page)

or Andrew resided in familiar guilt. In both cases the feeling was unpleasant,

regardless of how hygienic they felt these activities to be. When I pointed out

that, despite their positive intentions, these habits appeared unkind, both got

the message. They had permission to consider their conduct in the light of

compassion, as a form of granting or denying self-care. Redefining their own

mental habits along the axis of “kind and conducive of happiness,” rather

than along dimensions of health or morality, offered them more freedom to

Chapter 21 Mindfulness-Based Interventions in an Individual Clinical Setting

413

experiment. How could each be different with themselves in the moment of

difficulty? Framing actions in terms of compassion, toward oneself as much

as toward others, in practice rather than as an abstract ideal, is both method

and fruit of mindfulness.

Note that none of the examples cited above depended on meditation or

formal mental training, nor is mindfulness invoked to the patient. They are

“interventions” that rest on the therapist’s understanding and personal expe-

rience, communicated in the language of commonsense to the patient. Nor

does the role of mindfulness necessarily lead to a turning away from one’s

history, in flight to the here and now. This is seen in the case of Carol.

Carol was an experienced meditator, but a novice to therapy, having kept

her difficult emotional life from her friends and her kind but unattuned hus-

band. None knew the sort of emotional torment she carried for most of her

50 years. Carol’s mother had been an indifferent parent, entirely uninter-

ested in babies or children, a fact made clear in her failure to mirror her

gifted daughter’s efforts to be seen and accepted. Carol was desperate not

to disappoint her mother, but inevitably failed, as her mother wanted only

to be the center of attention and the life of the party. Her father was loving,

but intolerant and angered by any expression of dissent by Carol. She felt as

though she did not exist, and as a young girl would rock on her bed, repeat-

ing “I
do
exist.” Though she was academically gifted and later, professionally

successful, she received no recognition from her parents, nor nourishment

for herself, for her accomplishments. She felt counterfeit, learning to hide

beneath an exterior of competence to mask a deep sense of illegitimacy. In

adulthood she earned a doctorate, but every step was an enormous chal-

lenge, as she felt she lacked the right to the self-assertion implied by creating

works of original scholarship. What seemed like a natural expression of com-

petence required Herculean effort to overcome a commensurate inner resis-

tance. It was as though she had one foot fully on the gas pedal and another

on the brake. Carol was in a helping profession, and though socially com-

petent, being with others was deeply fraught and exhausting. She avoided

unnecessary contact for measured periods of time.

Carol chose me as her therapist because she knew of my interest in med-

itation, though we rarely discussed – and never used – meditation or mind-

fulness. However, her meditation experience was crucial to the therapy. She

had developed some capacity to tolerate her difficult emotional experience,

enabling her to endure the overwhelming early months of the therapy. The

fear and shame of speaking her formerly disavowed and unspoken thoughts

left her trembling and tearful, and she had to sit in her car for a long spell

after our sessions. She dreaded the sessions, but was surprised to feel relief

as well. Together we learned to pace the therapy to keep it manageable. I

was deeply impressed with her courage.

By contrast with Lydia who needed assistance dislodging her attention

from the personal archeological investigation that characterized her previ-

ous therapies, Carol needed to open to her history and difficult emotional

content, to enter and reclaim her story. In this movement she was honoring

the truth of her experience, which she had formerly sought to deny. This is

the work of conventional therapy, though it felt as if conducted on a high

wire. At one point I asked Carol if she felt there was anything authentic in

her experience. She thought a moment, and said that the direct experience

414

Paul R. Fulton

of the breath, encountered in moments of silent meditation, felt authentic.

While Buddhist meditation is often described in terms of seeking to illumi-

nate the illusory nature of the self, in meditation Carol had found a way to

locate herself, to herself. She was familiar with the Buddhist doctrine of no-

self, but said clearly, “That’s not what this was about.” We both understood

that the self she was in need of inhabiting was something different from the

illusory self described by Buddhist psychology, and we understood that both

activities were real and valid.

Carol’s journey was perilous, and I am convinced that she would have

been unable to undertake it were it not for the qualities of courage and forti-

tude cultivated in her years of meditation practice. It enabled her to become

more real to herself as a counterbalance to her sense of inauthenticity. This

sort of contribution can never be reduced to a set of techniques, a formula-

tion, or a perspective. Nor was her meditation a substitute for psychotherapy,

addressing difficulties that could only be fully summoned in relationship. In

meditation she had skillfully found a form of self-care and a source of emo-

tional survival. Though not an explicitly applied technique in the therapy, as

part of her own background it was an essential ingredient in her treatment

and her life.

Becoming More Explicit

Some uses of mindfulness and its underlying principles are nearer the explicit

end of the spectrum. I have often shared specific suggestions lifted more or

less directly from Buddhist lore, to good effect.

Leonard was a regional vice president of sales for a large national furni-

ture company. He lived in terror of his semiannual sales presentations at his

company’s national office, and would over prepare with reams of overhead

slides and notes. I had referred him to a MBSR program, from which he had

received some benefit, but his fear of these meetings kept him awake at

night. I told Leonard of a sermon given by a Zen master, which, in its entirety,

was two words long: “Soon dead.” Leonard was delighted, and was excited

to tell me, after his return from the sales meeting, that the only notes he

brought with him were these same two words written large on a legal pad.

Leonard knew his material cold, and paradoxically, his voluminous notes only

added to his anxiety. The reminder of the proper place of a sales presenta-

tion in his life was freeing, and he gave his best presentation ever. Rather

than heighten his anxiety, the reflection on life’s transience allowed him to

loosen his frightened grip on how his sales performance would define him.

He saw this event from a larger perspective.

Andrew often wondered when it was appropriate to correct a subordinate,

and how to distinguish when he was acting skillfully from when he was

speaking from anger.

I suggested that when faced with this uncertainty, he could apply three

questions, which I had lifted directly (without full attribution) from one of

the Buddha’s own discourses (the Abhaya Sutta). First, is what he wants to say

true? If not, then don’t say it. If it is true, he might then ask if it is beneficial

to say it. If it is both true and beneficial, then ask if it is the correct time and

place to say it. Besides requiring a moment to reflect (which already helps

Chapter 21 Mindfulness-Based Interventions in an Individual Clinical Setting

415

curtail an impulsive response), posing these practical questions to oneself

provides a way to practice non-harm, thereby avoiding escalation of one’s

own anger and aggression.

The Buddhist formulation for working skillfully with emotions differs from

the clinical notions of “abreaction,” “getting it out,” or catharsis. Anger or

hostility are seen as harmful, whether directed toward others or, through

judgment and self-rejection, toward oneself. While knowing difficult emo-

tions in the fullness of mindful awareness is essential, expressing them in

speech or action requires great care to avoid fueling the anger. This practice

of full present-moment awareness of a difficult emotion delicately balanced

against and verbal/behavioral restraint is a well developed practice in Bud-

dhist psychology.

Consider this dynamic in the case of Margaret, formerly a teacher but now

disabled by the cumulative debilitating effects sadistic childhood abuse. She

had repeatedly asked her neighbor not to walk her dog in Margaret’s tiny

yard. One day, called to the yard by the nearby sound of a fire truck’s siren,

she found herself standing in the midst of voluminous dog manure. Enraged,

she smeared the neighbor’s porch, door, and outdoor children’s toys with the

manure. Then, terrified of what she had done, she called the clinic where I

was providing backup coverage for her vacationing therapist, for an emer-

gency appointment. The “expression” of anger had shaken her badly, and

she was frightened. In the course of our meeting I asked her if there was

someone about whom she felt kindly, even in the midst of this storm. She

was able to locate feelings of kindness toward an elderly shut-in neighbor. I

suggested to Margaret that she consider doing something for this neighbor.

We made a follow-up appointment for the next day. When Margaret returned,

she told me how she had brought ice cream to her elderly neighbor, in the

process breaking the spell of her rage. She asked me, “How did you know?”

She was later able to speak to the neighbor who owned the dog about what

each of them had done, and resolved it amicably in a way that had seemed

impossible in the heat of her fear.

The Buddha purportedly said that hatred is never appeased by hatred, but

only by non-hatred (Dhammapada 5). More than an elevated shibboleth, this

expresses a pragmatic approach to difficult emotions that does not deserve

to be segregated in spiritual literature and admired from a distance. It offers

a practical way to work with inner experience in the interest of cultivating

inner and outer peace. Resisting actions rooted in anger, in speech or behav-

ior, toward oneself or toward others, is the practice of compassion, not one

of avoidance, isolation, or repression. As with most practices offered by the

Buddha, the encouragement is to see for oneself if they work to bring men-

tal peace.

In each case cited above is the invitation to patients to turn toward their

experience
as it is
, in full acceptance, not because of their like or dislike of

it, but because it is “true” for being present. In this movement is the subtle

suggestion that we need not be cured, fixed, or rid of anything as a precondi-

tion for healing. Relief from suffering may be difficult to win, but it is nearer

at hand than the notion of cure would suggest. When suffering is divested of

being regarded as evidence of failure, weakness, or illness, it may become an

opportunity to embrace more of life. This startling reframing points the way

suffering may gradually loses its sting.

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Paul R. Fulton

Conclusion

These few case examples do not suggest the application of interventions

cribbed from treatment handbooks, but neither are they esoteric or mysteri-

ous in nature. They arise from an understanding of the universal underlying

dynamic of human suffering. Books can provide invaluable guidance, but

mindfulness interventions and formulations arise naturally when, as thera-

pists, we have tested their utility for ourselves in the crucible of our own

experience. The sustained idiographic study of our own minds becomes the

seat of creative discovery, and the potential contributions of mindfulness to

therapy become as countless as the moments we spend with our patients.

When we have come to see how we entrap ourselves and how we might

cease such harming activity, we learn to see how others, too, fall into cycles

of suffering despite their deepest wishes for relief. We are better equipped

to provide guidance to our patients in this movement to well-being when

we have experiential understanding of this path, whether the use of mindful-

ness remains unspoken or becomes an explicit part of the therapeutic con-

tract between ourselves and our patients. Then all that we do as therapists

become mindfulness-based interventions.

References

Benoit, H. (1955).
The supreme doctrine
. Pantheon Books.

Brach, T. (2003).
Radical acceptance: Embracing your life with the heart of a Bud-

dha
. New York: Bantam Dell.

Dhammapada 5, The Pairs: Heedfulness. (1985). Acharya Buddharakkhita (Trans.)

Kandy: Buddhist Publication Society.

Fromm, E., Suzuki, D. T., & DeMartino, R. (1960).
Zen Buddhism and Psychoanaly-