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Cushion
and Couch
Fall 2013
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 Interview with Lauri Klein, LICSW, on MBSR
by Barbara Van Zoeren LICSW
Lauri Klein, LICSW has 30 years of experience in teaching and psychotherapy. She received training in MBSR at the Center for Mindfulness at UMass, and more recently trained with Zindel Siegel in MBCT. She writes and has published articles on Mindfulness, Compassion and Acceptance in local newspapers and the NASW's monthly, Focus. She maintains a private practice in Hingham, Massachusetts.
Barbara: What drew you to mindfulness?
Lauri: I started meditating in 1971 and I did TM (transcendental meditation) for a few years and then I kind of lost track of it, going to school, getting married etc..but my interest in meditation was always there.
Barbara: What drew you to TM in the first place?
Lauri: It was a counter-culture thing that everyone did. If you were any kind of a hippie or progressive thinker, you did TM.
Barbara: And the psychotherapy part came later?
Lauri: I aways wanted to be a therapist..ever since I did "T-group"/Sensitivity training in High School. What got me to where I am now in terms of bringing mindfulness into the work was reading Full catastrophe Living 15 years ago by Jon Kabat -Zinn. I was amazed at how integrated it was. What's right and important and what's true physiological came together. I think it is genius work! In 2003 I went out to U Mass and took the MBSR teacher training. I was going through a difficult time personally, and found the program really helpful. Being immersed in mindfulness for 8 weeks deepened my practice and my commitment to it. It taught me how to be present with my experience in a steady way so that I could hold it with more ease.
Barbara: So how do you introduce these concepts that you are so excited about to your clients?
Lauri: I'll sometimes just say, "I have a tool that might be helpful, would you like to try it?" and lots of times I'll just say to a client who comes in in an agitated state "Why don't you just take a moment, take a breath."
Barbara: Just "getting them into the room" with you.
Lauri: Yes, it's not like I say "I'm going to teach you to meditate." If they find it helpful I just teach them more of it. I use language like "taking a break," "getting in touch with your body" ... language that helps them to be more directly in touch with their experience.
Barbara: So where do you find the most exciting work is happening in the intersection of mindfulness and psychotherapy?
Lauri: What I'm excited about is how mainstream mindfulness is becoming. I love that there is not a clinician that I have met that is not, at least, curious about this. We are teaching people to stop wanting their suffering to go away. That is revolutionary. I feel like I am a more effective therapist.
Barbara: How do you gauge the progress of this approach?
Lauri: Well, in MBSR class, by week 4, I'm seeing changes in peoples faces, they're smiling more, they're having "ah ha" moments, they're excited and talking more positively about their lives even if they came into the program with a lot of physical or psychic pain.
In psychotherapy, I can tell if someone's improved if they can follow a direction such as, "Can you just be with that feeling?" and they do it with less resistance and fear.
Barbara: And is that another way that you bring mindfulness to your clients? Just asking them to "stay"?
Lauri: Yes. I feel calmer with my clients because I am also able to just "stay." I listen with more compassion and equanimity to difficult stories from clients because of my own mindfulness practice.
Teaching MBSR is part of my practice. I have been teaching for 10 years and this path is at the core of my life.
Barbara: Do you have any new work coming up that you'd like people to know about?
Lauri: I have written a small workbook with quotes and suggestions of ways to be mindful while grieving. It normalizes the experience of grief, including the tears. I am also starting an MBSR group for teens that will be called "Chill 101." And I hope to have an MBCT group up and running soon.
Barbara: What message would you want people to take away from working with you in this model or taking the MBSR class?
Lauri: That they are perfect just the way they are.
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Mental Triage: Using Cognitive Assessments to Facilitate Mindful Refocusing
by Sara Acker, Psy.D. 
I first began integrating mindfulness based perspectives and techniques into my primarily Cognitive-Behavioral work with clients while I was still in graduate school. At the time most of my formal training and supervision had been CBT oriented. I had resonated with the many metaphors and structure that CBT provides for therapeutic work, and found that the techniques were generally helpful to my clients when they were dealing with anxiety producing or intrusive repetitive thoughts. However, I sometimes felt that CBT wasn't entirely hitting the nail on the head when it came to these types of thoughts.
Firstly, I have always hated the term "irrational thinking," as not all thoughts that cause distress are inherently "irrational." This is particularly true in cases of intrusive, repetitive thoughts stemming from traumatic experiences. Whether it is repeating an experience from the past, worrying that something similar may happen in the future, or interpreting present events through this lens of experience, these thoughts are based in the client's own reality. To call them irrational seems to be invalidating at the least. Secondly, I found that using the traditional CBT methods of countering these thoughts didn't always seem applicable in these cases. There often was not a good way to reframe or counter a thought based on reality or past experience with a more "rational" thought, and I found that sometimes the act of trying to do this caused clients to get even more stuck in the thoughts and scenarios that were causing the anxiety. Techniques like thought stopping or blocking just caused more distress and frustration when they didn't work. Actively trying not to think about something seems a perfect way to ensure that you will think of nothing but it (i.e. Don't think about pink elephants! Don't think about pink elephants! Whatever you do, don't think about pink elephants!).
When I was introduced to the concept of mindful refocusing I found it to be a great technique to deal with intrusive thoughts (i.e. Notice the thought, don't judge it or yourself for having it, then let it go and refocus your mind on what is actually happening in the present moment). I started teaching the technique to clients alongside the CBT techniques, explaining the differences and letting them choose which one resonated with them in a given instance.
Mindfulness works very well, but only when you actually practice it in the moment of the intrusive thoughts. What I found was that clients often didn't think to use the technique when needed, or that they were sometime apprehensive about the concept of letting go of the thought, afraid that they would be ignoring something important that they should actually be worrying about. As one of my clients put it "I understand how to use mindfulness, but I'm not sure when to use it." Since most of my clients are college students and young professions who appreciate structure and specific direction, replying "All the time!" felt like a disconnect. I realized that CBT provided the structure for assessing thoughts and making decisions based on these assessments and tried to come up with a metaphor for assessing intrusive thoughts quickly into categories that would help clients decide how to respond mindfully. The concept of triage seemed to fit well.
In my experience, the majority of distressing and anxiety producing intrusive thoughts are about things over which we have absolutely no control. Whether it is going over events of the past, worrying about how someone else will respond to something we did or said, trying to predict exactly what will happen in a future scenario, or worrying about war in the Middle East, repeatedly thinking about it is not getting us anything other than stressed, and is likely interfering with our ability to focus on the moment and things that we actually may have some control over. I refer to these kinds of thoughts as Black Tags, as they are 'dead on arrival,' and focusing on them is often a waste of energy and attention. In these Black Tag cases the best option is to identify them quickly, then use mindful refocusing immediately, instead of wasting internal resources on processing the thoughts.
Sometimes however, worry and anxiety producing thoughts can actually be useful reminders that draw our attention to things that we do have control over which require some of our time, energy, internal resources, or problem solving abilities. The question then becomes "Is now the best time to be focusing on this?" You may actually need to spend some time composing a difficult email, making a phone call, or budgeting for your expenses, but if you are worrying about it while you are driving your car or over dinner with a friend, there is nothing you can really do about it at this moment and you are not able to focus your attention on your driving or listen to what your friend is telling you in that moment. I call these thoughts Red Tags. They are important and require resources, but not at this moment. In the case of Red Tag thoughts it is often helpful to quickly decide on a time in the near future to attend to the thought and take any needed action. This often allows the brain to let go of the thought more easily, knowing you will come back to it at the proper time. (i.e. "I have some time free at 6:30, I'm going to set a reminder in my phone to sit down for 20 minutes and worry about this, but right now I'm going to focus on the conversation with my friend").
The last category of thoughts are the kind that tend to stem from procrastination and anticipatory anxiety, often leading us to try to distract ourselves with other thoughts and activities, but being unable to fully focus on either. They often arise when now is actually a good moment to focus on the thought or complete a task, but we are reluctant to do so. I refer to these as White Tags, since they often don't require considerable time or effort once we actually focus on them. In these cases it is helpful to choose to mindfully shift focus from your current task, focus on the thought that has been bothering you, process it and complete any small associated tasks, then mindfully shift back to the present moment. If you are trying to write a paper but keep being distracted by thoughts about that email you need to send, it may be best to mindfully decide to take a brief break from paper writing and send off the quick email so that you do not have to worry about it anymore and can return to your paper, now being able to focus all of your resources on writing.
Many of my clients seem to resonate with the metaphor of triage and find the specific steps on how to do a quick cognitive assessment of the thoughts and decide on the best use of internal resources and focus to be helpful in coping with daily intrusive thoughts. One of my clients recently asked for an even more concrete set of instruction on how to implement this, so together we came up with a flow chart for decision making when she was having recurring distressing thoughts. Although the metaphor doesn't apply to every scenario or work with every individual, I find it is a good jumping off point to introduce clients to using mindfulness in an approachable way.
Sara Acker, Psy.D. received her doctorate in Clinical Psychology from the Massachusetts School of Professional Psychology. She currently has a private practice in Boston's Back Bay neighborhood, where she specializes in incorporating CBT and Mindfulness based therapies in the treatment of anxiety and stress related medical issues.
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Book Review
by Laura Fisher, Psy.D.
Mindfulness continues to be a growing phenomenon. Just recently, Thich Nhat Hanh traveled to Boston to speak about the necessity of mindfulness practice in our daily lives, and inspired therapists to use mindfulness as a way to alleviate suffering in the world. Psychotherapists have a unique ability to relay mindfulness practice to individuals who experience some of the highest levels of suffering. It is therefore very timely that Zindel Segal, J. Mark Williams and John Teasdale have revised their book, Mindfulness-based Cognitive Therapy for Depression (2nd edition) to aid in this process.
This book provides a very comprehensive blueprint for offering mindfulness-based cognitive therapy (MBCT) to individuals who are recovering from major depressive disorder. The book begins with a comprehensive look at the process and development of the program presented by these authors. The authors discuss their rational for developing this program, research that supports its efforts to combat recurrent depression, and the pitfalls that they encountered along the way. For instance, the authors did not initially think that instructors needed a personal practice of mindfulness meditation. Shortly after the piloted program, however, they insisted that this was a non-negotiable aspect of the program overall. They also insisted that instructors take a course in the program as a participant first prior to becoming trained as a MBCT instructor. Another interesting aspect of MBCT, one that deviates from other group models of treatment, is that instructors are active participants in the group activities. They do not merely instruct and watch - they model actual meditation and mindfulness practice by doing the exercises themselves in session. There is a strong emphasis placed on fostering kindness and self-compassion, both for the instructor as well as for the participants.
The program itself is loosely modeled after Jon Kabat-Zinn's famous Mindfulness-Based Stress Reduction Program (MBSR). The authors discuss and delineate eight comprehensive sessions that can be used sequentially to teach individuals about ways to restructure their thoughts and behaviors. Each session builds on the previous session and requires a fair amount of "homework" from the participants each week that forms the basis for many of the discussions in the group format. All sessions begin with a meditative practice and usually include smaller opportunities to practice mindfulness with the direct guidance and modeling of the instructor (e.g. eating a raisin, looking at a tree, etc. ). Handouts are offered at every session and the authors generously provide access to the handouts via internet or in print form. There is also a series of recorded meditative practices that participants can use at home, also provided via internet to those who buy the book.
Probably most useful, however, is not the "nuts and bolts" details offered in each session breakdown; rather, the authors offer detailed examples of actual participant responses to session activities. They provide a clear responsive style that one can use when helping participants navigate through the eight sessions, emphasizing a disposition of curiosity and inquiry versus "fixing" or rushing to solution based responding. Mindfulness topics include universal issues such as mind-wandering, boredom, irritation, falling asleep, and restlessness. More specifically, the authors address how to guide participants who experience pain in their practice as well as ways to counteract trauma-based responses. It is in this vein that the book becomes most useful to the individual practitioner, as many of these exact comments and/or experiences come up in individual mindfulness-based therapy as well. Therefore, even psychotherapists who have no intention of providing group treatment could cull this resource for nuggets of useful information. And, although this program was initially developed for individuals with major depression, it could be easily translated to help individuals with anxiety, stress management issues, life stressors, and other forms of mental illness. Worth having on your shelf!
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