Clinical Handbook of Mindfulness (42 page)

problem.

Chapter 8 Mindfulness and Feelings of Emptiness

143

Clinical Application of Mindfulness to the Experience

of Emptiness

Practical Issues

A mindfulness-based intervention with patients affected from a pathological

“feeling of emptiness” should be carried out by an expert therapist in the

practice of meditation. In addition, the therapist should have good clinical

competence with respect to all the psychological problems of the patient

toward which the intervention is directed. The therapist should be ready

to effectively deal with the eventual intense reactions that could be activated

during the sessions, including dissociative crises and intense states of anxiety

or escape.

Many patients who feel emptiness have a long history in invalidating envi-

ronments where their emotions, feelings, and needs have been denied recur-

rently, and the only remaining inner criteria is the one labeling their own

inner experience of the moment as unreliable or dangerous. It is therefore

useful and important to help the patient trust and believe what he or she

is feeling, in his or her own cognitive, emotional, and sensory experience,

learning to listen to herself/himself. Furthermore, a regular practice of mind-

fulness by the patient outside of the therapeutic setting is necessary. It is vital

that he/she has the possibility to find a small amount of time to dedicate to

meditative practice every day (even 10–15 minutes). This intervention could

be integrated in a structured mindfulness-based program (e.g., MBSR, MBCT)

or form a specific independent intervention that could be implemented in

an individual or group setting.

The final goal of this training is to lead the patient to explore and confront

his or her own emotions, mainly anxiety, which, as we have hypothesized

above, appears to be strictly related to the emptiness experienced in certain

types of disorders. As suggested by
Trobe-Krishnananda (1996),
the objective is to penetrate the fear in depth, but with awareness, compassion, and

understanding, giving value to these feelings and creating an inner space to

allow patients to feel, observe, and accept.

Venturing into this layer of vulnerability is not an easy task for the

patient affected by feelings of pathological emptiness. As we have previously

explained, these people are used to activating a set of avoidance strategies

and mechanisms in order not to feel the suffering. This “shell” keeps psy-

chological fear and pain away, even at the cost of developing alexithymia or

turning psychological suffering into a physical one, sometimes putting the

patient’s life at risk.

In our opinion, approaching the emotional sphere should take place in a

gradual way, with the utmost caution. The activation of emotions at a neu-

rovegetative level is often undifferentiated and can be the same for different

emotions. Any element of this activation can lead the patient back to a state

of emptiness, given the strong evocative potential for emotions associated

thereto. Every session, in such a structured intervention, should include a

gradual increase in the level of difficulty, that is, taking the patient a little

closer to the stimuli, situations, and feelings connected to emptiness. Every-

thing has to take place in a completely acceptable and non-judgmental frame-

work. In order to do this, we suggest starting the intervention by teaching

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Fabrizio Didonna and Yolanda Rosillo Gonzalez

patients to initially focus attention on exteroceptive stimuli, which are usu-

ally less anxiety inducing, doing exercises like mindful seeing or hearing, or

mindful walking (see Appendix A). Only at a later stage, during the course

of the program, are they conscientiously drawn closer to their inner feel-

ings and, therefore, to the enteroceptive experiences; some exercises such

as body scan or sitting meditation (see Appendix A) would be suitable for

this purpose
(Didonna, 2007,
paper submitted for publication).

Once these abilities have been consolidated, for example, “letting go,” not

passing judgment on their own experience, or “trusting” their own percep-

tions (see also Chapter 11), patients should be in a position to be in contact

with thoughts, feelings, and negative mindsets without enacting avoidance

behaviors. Moreover, during the course of the treatment, patients have the

opportunity to observe their own state of emptiness, to become aware of

its components, and above all, to perceive how secondary emotions and the

increase in emotional reactivity in those situations have decreased, reducing

the level of suffering of this experience. The patient should no longer judge

or blame himself/herself for feeling what he or she feels.

Staying in Touch with the Feeling of Emptiness

At a certain point in the therapeutic program, the patient should directly

face the experience of emptiness. Specific exercises can be developed to

help the patient to voluntarily enter into such a state. The fear of feeling pain

can keep patients distanced from their own feelings. A particular atmosphere

of acceptance, presenting them with a gentle invitation to get in touch with

what they fear, is required. There must be no pressure or judgment. In order

to recreate this state, it might be sufficient to ask patients to remember the

last time they felt this way, or the time when the feeling was so strong that

they did something particular in order not to feel it. Being “with themselves”

in those moments was not a pleasant feeling.

These experiences can be explored with the guidance of the therapist,

helping patients to focus their attention on certain aspects in order not to

let themselves go, thereby avoiding passing judgment on themselves. The

most important thing is to learn to recognize what is happening, intimately

bonding with what was previously avoided. The instructions could invite the

patient to focus their own attention on those aspects, for example, allow-

ing them to remain inside their experience, preventing the activation of the

escape behavior, or observing how the sense of threat is perceived, or simply

examining when and which type of impulses occur during the session. This

could help, in some cases, to identify even the nature of their own fear con-

nected with the feeling of emptiness (abandonment, failure, violence, judg-

ment, and the thought that the fear will never end) more easily recognized

observing the contents of thoughts in this state.

It is natural for these patients to fear being overwhelmed by the feeling of

emptiness they encounter. The idea of being in contact and remaining with

the feeling is terrifying. For this reason, the method used needs to be well

consolidated, offering a “safe base” made up of previously acquired experi-

ences and abilities, which are needed to deal with stimuli with greater aver-

sive potential. The approach has to happen gradually, with the maximum

sensitivity and without haste, but with the knowledge that with mindfulness

Chapter 8 Mindfulness and Feelings of Emptiness

145

meditation, the individual needs to go through the feeling of emptiness if he

or she wants to be free.

Some possible instructions that can be used in order to allow patients to

better understand and stay in touch with the feeling of emptiness, in a mind-

ful way, are the following (adapted from
Trobe-Krishnananda, 1999):

1. Look over your childhood essential needs. Ask yourself: “Do I have a hole

related to this need?”

2. Then focusing on this particular hole, ask yourself: “How does this hole

affect the way I relate to myself?” and “How does this hole affect the way

I relate to people and life?”

3. Staying with this hole, ask yourself: “How do I feel this hole inside?” and

“Which sensations do I feel right now and where in the body?” Allow

yourself to notice your feelings in this moment and realize how they are,

however, different from you, they aren’t you
. . .
breathe with them. Try to

observe them, without judging them, carrying a sense of gentle curiosity

toward that experience. You can approach or recede from these feelings,

and finally try to let them go.

4. Explore your needs: “What thoughts and feelings arise when you con-

sider your needs?” (e.g., “I am weak or needy if I want this” or “I don’ t

feel I have the right to want or need this”). Let’s grant them the possibility

and the necessary time to cross our mind
. . .
; “We accept and are com-

passionate toward these thoughts, realizing that when they were formed,

they certainly made sense and had a function even though we have now

lost them
. . .
let’s try to think how much they need us to exist, without

us they don’t have strength or meaning
. . .
let’s allow ourselves to observe

and understand them without judging
. . .
”; “Let’s give ourselves permis-

sion to immerse ourselves in our inner experience even though it hurts

and causes pain, breathing together, crossing it and letting it envelop us in

order to reemerge at a certain point
. . .
let’s try to observe what happens,

what changes
. . .
trusting our experience.”

• We may also ask the patient to write down, if possible, what beliefs he or

she holds inside about having or expressing these needs.

• And eventually may ask: “What were you taught as a child about having

and expressing your needs?” (e.g., “It is selfish to have needs and wants”

and “Men should not have needs and wants”). “Be kind and do not judge

yourself and your own thoughts. There is nothing that you need to do

or not do in this moment. Just stay with yourself and your breath now,

moment by moment
. . .
”.

What Can the Instructor Do

•
Consider that sense of pathological emptiness is only the manifes-

tation of a wider range of psychological difficulties of the patient
.

According to
Teasdale (2004),
it is necessary to keep in mind the speci-

ficity of emotional disorders examined as well as some specific interven-

tions likely to help the patient in the effort to modify the processes (apart

from the contents) of his or her own modes of mind. Mindfulness must be

used in an overall therapeutic strategy within a framework of clear under-

standing of the emotional problems of the patient.

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Fabrizio Didonna and Yolanda Rosillo Gonzalez

•
Share with the patient a new conceptualization/formulation of his

problem
, helping him or her to formulate an alternative vision of the

feeling of emptiness through a cognitive-behavioral model of understand-

ing the functioning of his or her problem. Some mindfulness-based train-

ing, like MBSR, MBCT, or ACT, use homework (ABC, self-monitoring form,

diary, etc.) as a vehicle for explaining the various cognitive processes at

the basis of the disorder and of their functioning modes when they occur.

•
Welcome the difficulties of the method reported by patients from

the onset
. We need to use the difficulties from the beginning as an oppor-

tunity to teach new attitudes for facing the problems. Relating to the dif-

ficulties with curiosity and interest, trying to accept them rather than

reject them, defines the bases for a mindfulness approach to thoughts

and negative emotions, especially those deriving from experiences of

emptiness.

•
Share one’s own experience during the meditative practice, invit-

ing patients to do the same
.
Segal, Willians, and Teasdale (2002,
p. 55) talk about the approach and attitude of the instructors observed in the

MBSR mindfulness program: “the stance of the instructor was itself ‘invi-

tational’. In addition, there was always the assumption of ‘continuity’

between the experience of instructor and the participants (
. . .
)”. The

assumption was simple: Different minds work in a similar way, and there

is no reason to discriminate between the mind of the person asking for

help and of the person offering it.

Conti and Semerari (2003)
describe
sharing
in a therapeutic context as a set of explicit interventions where it is stressed that some aspects

of the patient’s experience are shared or shareable by the therapist him-

self/herself. Sharing interventions include elements of both validation and

self-disclosure. With this technique, in fact, the therapist implicitly vali-

dates the patients’ experience through the acceptance and recognition of

the shared dimension and, in so doing, reveals one’s own mental state.

However, this does in no way imply that the patients should feel forced

to report their own experience. It must be clear that it is a free choice

that does not affect the practice. It is enough to be present and to listen

in order to take part in this intervention.

•
Eliminate any type of judgment during the practice or the sharing,