By Robert Hindman, PhD

Mindfulness and acceptance-based interventions, such as those in Mindfulness Based Stress Reduction and in Acceptance and Commitment Therapy, are becoming increasingly popular among both therapists and clients and have been referred to as the “third wave” of behavioral and cognitive therapies.  While there isn’t a single agreed-upon definition of mindfulness, it’s often described as maintaining attention on present moment experiences while taking an orientation of openness, acceptance, and curiosity (Bishop et al., 2014).

Consider the example of Katie, a 28-year-old female who comes to treatment because she’s “always been a worrier,” “worries about everything,” and “can’t stop worrying once [she’s] started.”  Let’s first discuss what the components of a purely mindfulness-based treatment might look like for Katie.  A mindfulness-based therapist might start by guiding Katie through a mindfulness of the breath meditation, instructing Katie to refocus attention back to the breath once she notices her attention wandering to other things, such as potential worries about the future.  She is told to avoid evaluating the content of the thoughts because “Thoughts aren’t facts.”  Katie learns that there’s no point in worrying about the future because the only moment in time she’s able to be in contact with is the present.  Through this treatment, Katie begins a daily meditation practice and uses mindfulness to reduce worry and be more focused on the present moment.

Would this mindfulness-based approach be incompatible with CBT?  Therapists often mistakenly think that CBT teaches clients to evaluate the content of each worry.  How could integrating mindfulness into CBT be helpful for Katie?

Integrating Mindfulness

First, I would say that my CBT treatment for Katie would be based on her cognitive conceptualization.  With her conceptualization guiding treatment, I would use mindfulness as a potential intervention–as opposed to a guiding principle.  Instead of initially teaching her mindfulness to reduce worry, I might begin by helping her evaluate the content of one of her worries.  Doing this enables Katie to learn that “Thoughts aren’t facts” through her own experience of collaboratively evaluating a worry, instead of her therapist just telling her that.   Next, I would help her evaluate her beliefs about the worry process, including her beliefs that “Worry helps prepare me for danger,” and “Worry is uncontrollable once it’s started.”  If I don’t evaluate her beliefs about worry, she’ll be more likely to continue worrying despite having a strategy to reduce the process.  Now that Katie believes “Thoughts aren’t facts,” “Worrying doesn’t prepare me for danger,” and “Worry always comes to an end,” I can teach her mindfulness.

Instead of introducing mindfulness as a way of life, I’ll refer to it as a skill to help her disengage from worrying.  Also, I’ll start the mindfulness intervention by asking her to worry about a current concern, before guiding her through the mindfulness of the breath exercise.  Inducing worry first is meant to replicate both the worry and the elevated anxiety that happens outside of session, so her mindfulness experience in session is more likely to transfer to her day-to-day life.  This experience also teaches her that she’s able to disengage from worry even when her anxiety is high.  I’ll record the guided mindfulness exercise on Katie’s phone because clients often find it easier to practice guided mindfulness exercises outside of session when they are recorded.  For her Action Plan, I’d recommend that she review her therapy notes daily, which serves as a reminder of her new beliefs about worry.  She would practice mindfulness of the breath daily by following the recording to help her develop the skill of disengaging from worry.  Finally, she would use that skill throughout the day by shifting attention momentarily to the breath whenever she notices herself worrying.  However, unlike during the mindfulness exercise, I’d instruct her to keep her eyes open as it is obviously impractical for her to close her eyes in situations such as driving.

Adding mindfulness into CBT can improve outcomes when mindfulness-based strategies are appropriately adapted, guided by a cognitive conceptualization.

References

Bishop, S. R., Lau, M., Shapiro, S., Carlson, L., Anderson, N. D., Carmody, J., & Devins, G. (2004). Mindfulness: A proposed operational definition. Clinical Psychology: Science and Practice, 11, 230–241.