Synergies #3: Mindfulness and Psychotherapy

Previous articles in the Synergies Series have described the benefits of mobilizing the patient in the direction of lifestyle changes and prioritizing self-care. The central idea is that the development of healthy routines (biological, social, and spiritual) is the crucial element of “Wellness” and “Fitness.”

It's the role of the therapist to help the patient understand why healthy routines are important. They should tailor the "Why" to the patient - for example:

• Some people may view psychiatric medications as a biological need, while others may be more motivated by connecting it to their emotional or social needs.

• Some may view religious services as a spiritual need, while others may see it as a social need.

• Exercise, depending on the type, could be viewed as a biological, social, emotional, or spiritual need.

However they choose to classify specific activities, it's important that the patient pays attention to:

• Healthy diet

• Regular exercise

• Feeling connected to other people/nature/greater power

• Taking medications as prescribed

• Emotional intelligence & balancing

• Intellectual stimulation

It's also important that the therapist helps the patient understand that all of these different areas can influence the others; when we fail to pay enough attention to one area, it can negatively impact others. Also, when strategizing with patients, you can help them to come up with a plan to satisfy more than one need with a single activity - for example, hiking with friends is both exercise and social, and may also fulfill a spiritual need.

Psychological Needs

Many of the aspects previously mentioned can be classified as Psychological needs, including emotional, and intellectual needs.

• Calming and clearing the mind with mindfulness or meditation

• Activities that increase feelings of productivity or creativity

• Feeling compassion towards others

• Losing ourselves in a task or activity (such as described in Flow by Csikszentmihalyi)

Social Needs

Every person has some level of social needs, which vary from the minimal interdependence we have on each other for basic necesseties (food, shelter) to more complex social fulfillment. Social needs can often overlap or be interdependant with other types of needs

• Exercising or eating with others

• Spiritual community

• Feelings of personal accomplishment (pride, productivity) may be dependent upon other's approval

Spiritual needs may be less obvious and historically clinicians have downplayed it's importance unless specifically mentioned by a patient. However, spiritual issues deserve just as much attention as other types of needs, and clinicians should make a real effort to help their patients to define what "spirituality" means to them, and how their spirituality is connected to other types of needs - because they often are. Issues about self worth, hope, judgment of self, guilt, acceptance, forgiveness, are just a few. 

It's important to note that I have used the term "Spirituality" and not "Religion", because they are two very different things. Examples of spiritual needs would be appreciating the natural beauty of a sunset, or taking time to acknowledge the awesomeness of the universe (whether or not you believe in a “Creator”).

The Role of Psychoanalysis in Behavior Change

Historically, many psychotherapies have focused on understanding why people act or think the way they do, and trying to resolve breaches in relationships through the new relationship with the therapist. These types of therapies are helpful, but all too often therapy is bogged down on these areas, never getting to the patient actually changing the way they think or act. Clinicians and patients should view “Understanding” as not a goal but as a tool that will help them to accomplish goals such as improved self-esteem, self-care, and decision-making.

Psychoanalysis focuses primarily on the psychological preperation required for long-term behavioral change; working to unblock resistances and obstructions to self-care such as:

• Self-worth issues

• Prioritization of personal needs before others’

• Assertiveness

• Exploration of the why behind current difficulties

The Role of Skills-Based Therapies

Oftentimes, it is enough for patients to understand that they...

• Didn’t receive the love they needed growing up

• Never learned how to understand, validate, and regulate their emotions.

Psychological healing can come from clarifying and supporting healthy emotions such as grief, and sometimes this is enough. For other patients, simply understanding is not enough and is only the first step. Because they did not get what they needed as a child, they developed distorted thinking and destructive habits, and need help to develop healthy thought patterns and behaviors, such as:

• Productive time management

• Emotional intelligence

• Mindfulness

• How to challenge distorted thinking patterns that were explored using psychoanalysis

One valuable cognitive technique is to teach patients that their negative beliefs about themselves are ingrained; that they’ve grown up around them, and to some degree these thought patterns will always be a part of them. They should not wait for these negative beliefs to change before beginning to take care of themselves. Teaching people that they can learn to actually change their emotions can be powerfully motivating. More on motivational techniques in a future column.

Skills-based therapies teach the patient to take charge of their own life in the here and now to the extent that their biology, environment, and interdependence allows. In order for skills-based therapy to be effective, the patient has to be:

1. Psychologically present and clear-minded

2. Able to read their emotions clearly

3. Examine automatic thoughts, biases, and judgments, and question them

4. Able to think through behaviors and consequences without immediately reacting,

5. Able to choose the actions that best fit their values and priorities

I basically just defined Mindfulness, and that is no accident; it's the most effective and efficient strategy to accomplish healthy behavior change.

We don’t have to teach the patient about mindfulness ourselves, but we should at the very least refer patients to appropriate resources. These websites, books, podcasts, articles, and retreats should teach them about Mindfulness and how to use Dialectical Behavior Therapy (DBT) and Mindfulness-based Cognitive Therapy (CBT) techniques in their everyday lives.

It is very each to teach mindfulness - it's simple to explain and accessible to practice. The patient sorts out past, present, and future thinking (and being), and to examine thought patterns and impulses:

• Observe their emotions and describe them

• Recognize distortions, biases, and other "programming" from the past

• Practice compassion towards others and self

Another important skill the patient learns with mindfulness is to observe those inner processes without running away, judging, or immediately acting on them. All these techniques help immensely with self-esteem, anger management, intimacy, and many other areas.

Specific Benefits of Mindfulness

When the clinican understands mindfulness and uses it in therapy it can be a huge benefit to patients' lives. Mindfulness concepts can be applied everywhere once you know what to look for.

Anxiety & Other Intense Emotions

Patients can learn “Emotion regulation skills” so that as they learn to distruptive intense emotions they can apply techniques to calm themselves or change what they are feeling.

Post-Traumatic Stress Disorder (PTSD)

Teaching mindfulness and emotion regulation skills before going into past trauma allows the patient to approach the past when ready with new healthy coping skills, such as:

• Actively being able to separate past from present

• Confidence in their ability to calm themselves when they start to become emotionally dysregulated

Attention Deficient Disorder (ADD) & Difficulties Managing Tasks

Mindfulness can help with concentration, prioritization, task management, and overall productivity. There are a surprising number of distorted thoughts and unhealthy coping mechanisms that can go along with ADD and task mis-management; becoming mindful of these can benefit anyone with ADD or concentration related symptoms.

Summary

Clinicians should have discussions with patients about their priorities and goals, and encourage them to develop values. Many patients are so focused on pleasing others or “figuring out” the meaning of things that they haven’t taken time to develop their own values. These values should include routine self-care, and become the cornerstone or foundation for a new life. Applying these skills and seeing results is very motivating to patients. There is usually a snowball effect as they “get it”. When you monitor these areas, if you see slipping back from the “self-care” routines that can become an early indicator of relapse. “Self-care” routines clearly add a buffer of prevention. I’ve also expanded on the interaction between mindfulness and medications here

Developing these healthy self-care routines is just the first step; long-term maintenance requires daily re-commitment to healthy habits. One of the roles of a therapist is helping patients to prevent relapse - teaching them why long-term maintenance is necessary and strategizing with them on how to prevent falling back into unhealthy patterns.