Clinical Handbook of Mindfulness (41 page)

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share them with him. There is only emptiness when I think I’ll never be

able to listen to his secrets, there won’t be any requests of advice, I won’t

be able to see him growing up, becoming a man. I won’t be able to get

excited about his first love, a disappointment, a defeat or a victory. There

will only be the lack of a relationship based on participation, bonding,

joining of forces that was just starting and I was really waiting for. Why

has all this been denied me? Everything has become null and void when I

think of all that has been left suspended: it’s like an abnormal condition

in my life that I don’t know how long will last. It’s as if, while I’m watching

a TV programme, this suddenly changes and I’m left here waiting in vain

for everything to go back to normal, to the previous programme
.

In this patient, like in other individuals suffering from major depression,

the deep and overwhelming feeling of emptiness was determined on the one

hand by what was no longer in her life, but on the other hand by the loss of

what there would not be in the future and that never more will be, that is,

the ineluctable interruption of a plan, a
loss in the future
.

How Mindfulness Can Help to Deal with and Overcome

the Feeling of Emptiness

There is nothing greater than anything else

Plutarco, Adversus Colotem

Mindfulness as an Anti-avoidance Strategy

If we hypothesize the feeling of emptiness as a sort of emotional avoidance

of a phobic stimulus situation (negative emotion), it is then right to think

that the treatment should include the exposure to the stimulus provoking

fear in the absence of the feared consequences. During this exposure, the

patient is asked to pay attention to the stimuli that he or she usually system-

atically avoids in a controlled way, showing him or her with the same stimuli

(imaginatively or in vivo), thereby hampering avoidance so that the patient

can experience the harmlessness of the stimulus.

It is assumed that exposure causes habituation to the stimulus or a process

of extinction of the avoided reactions, favoring the emotional coping, that is,

preparing the subject to face the emotions resulting from feared situations.

Baer (2003)
affirms that among the mechanisms explaining the clinical effectiveness of mindfulness, one of the most important is experimenting through

exercises a form of “exposure” to various types of information (extere-

oceptive and interoceptive) that are usually avoided and/or suppressed.

Kabat-Zinn (1982)
used mindfulness on patients affected by chronic pain.

The author has stated that guiding patients to develop a non-judgmental atti-

tude with respect to their own feelings of pain, and helping them to curi-

ously observe them without reacting impatiently or intolerantly, resulted in

a significant reduction in suffering, not related to the sensory perception of

pain but to their own emotional reactivity (aversion) toward the perceived

feelings. This can be considered an extended exposure associated with an

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Fabrizio Didonna and Yolanda Rosillo Gonzalez

attitude of acceptance of physical pain. The result would be an increase in

tolerance toward the suffering and a reduction in the reactive emotionality.

Linehan
(1993)
starts from the theoretical assumption that BPD emotional distress is mainly derived from secondary responses (e.g., deep shame, anxiety, anger, or guilt) to the primary emotions that often, instead, would

be adaptive and context appropriate. A reduction in this secondary stress

requires exposure to primary emotions in non-judgmental circumstances.

In a similar context, awareness and non-judgmental attention toward one’s

own emotional responses can be considered a technical exposure. The basic

concept is that exposure to intense or painful emotions, without associating

negative consequences, will extinguish their ability to stimulate negative sec-

ondary affects. If a patient judges negative emotions as “bad” or “wrong,” it

is obvious that every time he or she experiences them, he or she will have

feelings of guilt, anger, and/or anxiety. Adding these feelings to an already

negative situation will only increase the patient’s distress and will only make

it more difficult to put up with the anguish. Mindfulness is the ability to

ensure or the set of skills capable of ensuring that the patient enacts this

form of perception, taking advantage of all the assumptions needed for it to

be effective. During the practice of mindfulness, we can keep frequency and

duration of the exposure under control. The exercises can be guided so that

they will be clearly specified and last long enough. Intensity can also be man-

aged by leading patients to set their non-judgmental attention and awareness

on elements outside themselves and far from anxiety-producing stimuli: As

they progress in the process, they bring themselves closer to their physical

sensations, thoughts and, lastly, to their negative emotions. The validating

environment, during mindfulness training, accepts any experience originat-

ing from practice, informing patients that accepting reality does not neces-

sarily mean approving it.

Exposure is probably not the only active factor in the process of mind-

fulness clinical effectiveness that could refer to the experience of empti-

ness. The mechanisms implementing these effects are in our opinion closely

related to the development and initiation of meta-cognitive processes regard-

ing the aforementioned experience.

Detachment and Decentering

One of the more important processes in the state of mindfulness is detach-

ment (
detached mindfulness
;
Wells, 1997, 2000, 2006;
see also Chapters 5

and 11). According to the author, this attitude would be characterized by

meta-awareness (a form of objective conscience of thoughts), cognitive

decentering (acquired consciousness that thoughts are just thoughts, not

facts), attentive flexibility (self-regulation of attention including both
sus-

tained attention
and
skills in switching
, and meta-attention; see also next

paragraph and Chapter 11 of this volume), low levels of conceptual process-

ing (low levels of inner dialogue), and a low level of coping behaviors aimed

at the avoidance or reduction of the threat. This is the equivalent of affirming

that the patient becomes aware of his or her feelings mainly due to the ability

to observe them, implementing a decentering from them, and developing a

better understanding of his or her own cognitive functioning.

Chapter 8 Mindfulness and Feelings of Emptiness

141

Self-Regulation of Attention

Bishop et al.
(2004)
consider self-regulation of attention to be central among the main cognitive processes that lead to mindfulness (see also Chapters 5

and 11 of this volume).
Wallance and Shapiro (2006)
also say that there are two types of attentive ability: One deals with the ability to continuously

support voluntary attention on a familiar object without forgetfulnesses or

distractions; the other, called “meta-attention,” refers to the ability to moni-

tor the quality of the attention, quickly recognizing if he or she has yielded

to sluggishness or excitement. The concept of self-regulation of attention

would then include three sub-functions: the ability to shift attention from

one content to another, the ability to stay focused on a single object, and

the meta-attentive ability leading to recognizing the moments where the

attention has shifted toward other mental objects. In the process of dynam-

ics, the self-regulation of attention constantly interacts with two other fac-

tors: the unconditioned openness of behavior toward the tried experience

(acceptance equanimity) and the continual consideration given to the func-

tional objectives of the momentary task (intention). The self-regulation of

attention becomes extremely useful in helping subjects to focus on the

components of the experience of emptiness, overcoming the difficulties

that are often present in deciphering their own emotional and cognitive

state.

Acceptance

Acceptance, another basic component of the state of mindfulness, has an

essential role in allowing the patient to stay in touch with his or her own

experience of emptiness, thus allowing the exposure to painful stimuli,

whichever they are. Acceptance allows the patient, in a state of psychological

openness and willingness, and through a gentle curiosity to approach various

sources of aversive stimulation that has till that moment caused the person

behavioral patterns of escape, refusal, or avoidance. For
Hayes (1994),
acceptance is a position relative to which previously intrinsically problematic or

painful events become an opportunity of personal growth and development.

Donaldson (2003)
and
Wells (2002)
consider it a meta-cognitive process operating at a higher level than that of immediate experience, a “meta”

level implying the direct perception of thoughts, feelings, or intentions of

purpose.

Accepting is receiving, welcoming the experience of the moment, stay-

ing fully in touch with one’s own thoughts, emotions and physical feelings,

without reacting to and developing a decentered ability to observe them.

Acceptance gives us the possibility to see our experience in the moment as

it really is. However, accepting does not actually mean appreciating what

we accept. The experience of emptiness could for a certain period of time

be admitted and accepted. This would give the patient the opportunity

to observe the consequences of this contact without negatively labeling it

through judgment.

In a state of acceptance, the person recognizes that some aspects of the

experience cannot be changed while he succeeds in realizing the elements

that can. The patient will, therefore, channel his or her energies toward these

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Fabrizio Didonna and Yolanda Rosillo Gonzalez

latter ones, trying to
respond
, where possible, through a thoughtful action,

rather than
reacting
(with automatic and impulsive actions) to the distressing

experience in order to reduce, and often cancel out, the aversive psycholog-

ical component of the experience. All the signs that accompany the experi-

ence of emptiness are usually submitted to meta-evaluation (a meta-cognitive

process) by the subject; that is, they are affected by a negative meaning con-

sidered highly disagreeable or unbearable, leading the individual to various

attempts of suppression or avoidance. Unconditioned acceptance would be a

different way to relate to the experience that would reduce cognitive avoid-

ance, thereby eliminating one of the factors responsible for the suffering

(Didonna, 2007).

Letting Go

Letting go is the ability directly connected to acceptance that can fail to be

immediately experienced when the patient comes into contact with certain

disagreeable thoughts or feelings.
Kabat-Zinn (1990)
states that in the practice of meditation, we deliberately put aside that part of the mind clinging

to certain aspects of our experience and reject others. The non-attachment,

the letting go, is a form of acceptance of the things as they are. This ability

allows patients to give the same attention to all stimuli, regardless of his or

her need to hold on to or distance him/herself from those aspects of the

experience of emptiness that cause suffering, or “entrapping” them in a cer-

tain mental state.

Not Striving

Not striving is the attitude where the patient does not pursue any precise aim

during the practice of mindfulness. There is nothing that he or she should or

should not do. Nothing has to be reached. It is enough “to be” and to remain

in the present, bringing his or her own attention to himself/herself. We need

to ask patients not to want to attain any changes or expect to modify their

own experience of emptiness. The only thing they are to do is to remain

there and observe. The change, if it happens, will paradoxically be the result

of not having sought it out.

Identifying the Precocious Signs of Emptiness

Another important mechanism of change of mindfulness for the experience

of emptiness could be the precious aid given to the ability to identify the

feelings, thoughts, or situations leading to the feeling of emptiness early.

Mindfulness allows patients to gather these signs, which differ depending

on each patient’s own experience, from the onset, helping to identify the

suitable moment in order to use appropriate coping strategies and not to

remain “entrapped” in the emptiness that leads to having to resort to dys-

functional solutions.
Baer (2003)
suggests that mindfulness training may promote recognition of early signs of a problem, at a time when application of

previously learned skills will be most likely to be effective in preventing the