SIEGEL Kripalu Slides 2018

Mindfulness and Compassion in Psychotherapy Cultivating Freedom and Resilience Ronald D. Siegel Harvard Medical School ...

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Mindfulness and Compassion in Psychotherapy Cultivating Freedom and Resilience Ronald D. Siegel Harvard Medical School

Therapeutic Mindfulness 1. Awareness 2. Of present experience 3. With acceptance

Life Is Difficult, for Everybody

What is Mindfulness? • Sati in Pali  Connotes awareness, attention, & remembering

• In therapeutic arena, also includes  Non-judgment  Acceptance • Adds kindness & friendliness

Mindlessness • Operating on “autopilot” • Being lost in fantasies of the past and future • Breaking or spilling things because we’re not paying attention • Rushing through activities without attending to them

Mindfulness Can Help Us • To see and accept things as they are • To loosen our preoccupation with “self” • To experience the richness of the moment • To become free to act skillfully

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Breath Awareness

Mindfulness Practice is Not: • • • • •

Having a “blank” mind Becoming emotionless Withdrawing from life Seeking bliss Escaping pain

How it Works: Common Factors in Psychological Disorders Fly

Overwhelmed?

Intensity of experience

Capacity to bear experience

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The Thinking Disease

The Problem With Selfing

• Analyze past pleasure and pain • Maximize future pleasure and avoid future pain

Jung’s Shadow & The Separate Self

Therapeutic Progress Not about me

• Identifying with only some mental contents • Creates dissociated “Shadow”

Not about me

”mine” about me ”mine” about me about me

-- Adapted from Engler & Fulton

The Roles of Mindfulness Implicit

And I, Sir, Can Be Run Through with a Sword

• Practicing Therapist • Mindfulness Informed Psychotherapy • Mindfulness Based Psychotherapy

Explicit

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Affect Tolerance • Not “my,” but “the”  Anger

Embracing Affect • Beyond affect tolerance – embracing emotion  Our patients can only be with those emotions that we can embrace

 Fear

• All emotions experienced as transient

 Lust  Joy

 A teaspoon of salt in a pond

Not Knowing

Beginner’s Mind

How Does Mindfulness Help?

Forms of Mindfulness Practice

• Reinforces experiential approach • Helps free us from believing in our thoughts • Reduces narcissistic orientation • Connects us to the world beyond our personal pleasure and pain

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Decisions, Decisions 1. 2. 3. 4. 5. 6. 7.

Core Practice Skills 1. Concentration (focused attention) 2. Mindfulness per se (open monitoring) 3. Acceptance and Compassion

Acceptance & Compassion

Which skills to emphasize? Formal or informal practice? Which objects of attention? Religious or secular practices? Narrative or experiencing mode? Relative or absolute truth? Turning toward safety or sharp points?

Focused Attention vs. Open Monitoring • Concentration (FA)  Choose an object and follow it closely

• Mindfulness (OM)  Attend to whatever object rises to forefront of consciousness

Continuum of Practice Informal Mindfulness Practice

Formal Meditation Practice

Intensive Retreat Practice

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Telephone Meditation

Shower Meditation

Taillight Meditation

Formal Practice (Results May Vary) • Data supports effects of formal meditation • Structural and functional brain changes.

Choosing a Suitable Formal Style

Intensive Retreat Practice

• Some people are drawn to “spiritual” practices  Devotional and theistic practices

• Some people are drawn to secular practices  Science grounded  Not exotic

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Objects of Attention Coarse

• • • • • • •

Feet touching ground Sights and sounds of nature Taste of food Sound of bell Breath in belly Mantra Air at tip of nose

Religious or Secular? • “Spiritual” practices  Devotional and theistic

• Secular practices  Science grounded

• Seek cultural consonance

Subtle

Narrative Mode • Psychodynamic  Earlier, transference, other relationships

• Behavioral  How learned, how reinforced

Experiencing Mode • How is it felt in the body? • How does the mind respond?  Grasping  Pushing away  Ignoring

• Systemic  Maintained by family, community, culture

Relative Truth

Absolute Truth

• Human story        

Success & Failure Pleasure & Pain Longing Hurt Anger Envy Joy Pride

• Anicca (impermanence) • Dukkha (unsatisfactoriness) • Anatta (no enduring, separate self)

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Processing Trauma 1. Open to painful emotions

Timing is Everything

2. Explore the facts of trauma 3. See it through lens of dependent origination 4. Develop compassion

Turning toward Safety I • Outer or distal focus     

Walking Meditation Listening Meditation Nature Meditation Eating Meditation Open eye practices

Turning Toward the Sharp Points

Turning toward Safety II • Inner focus    

Mountain Meditation Guided Imagery Metta Practice DBT techniques

Different Strokes

• Moving toward anything unwanted or avoided

• Need for frequent adjustment of exercises

• How is it experienced in the body?

• Elicit feedback about the experience

 Pain, fear, sadness, anger  Unwanted images or memories  Urges toward compulsive behaviors

 Both during and after practice

• Titrate between Safety and Sharp Points

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When Mindfulness of Inner Experience Can Be Harmful • When overwhelmed by traumatic memories • When terrified of disintegration, loss of sense of self • When suffering from psychosis

Alternate Techniques when Overwhelmed • Eyes open, external sensory focus  Ground, trees, sky, wind, sounds

• Yoga practices to stretch and relax muscles

Decisions, Decisions 1. 2. 3. 4. 5. 6. 7.

Which skills to emphasize? Formal or informal practice? Which objects of attention? Religious or secular practices? Narrative or experiencing mode? Relative or absolute truth? Turning toward safety or sharp points?

Compassion in Psychotherapy

Motivational Systems Drive, excitement, vitality

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Contentment, safety, connection

Affiliative Soothing/safety

Seeking pleasure Achieving and Activating

Well-being

Threat-focused Protection & Safety Seeking Activating/Inhibiting

Anger, anxiety, disgust

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Compassion • Latin: pati; Greek: pathein (“to suffer”) • Latin: com (“with”) • Compassion means to “suffer with” another person.

Lovingkindness Practice

Compassion’s Relatives • • • • •

Empathy Sympathy Love Pity Altruism

Looking Through Another’s Eyes

• “Metta” practices  May I be happy, peaceful, free from suffering  May my loved ones be happy. . .  May all beings be happy. . .

Condon, Desbordes, & Miller (2013)

Paradoxical Responses • Universality of ambivalence  Highlight one pole, energize the other

• Negative emotions may arise  Cynicism, anger, sadism

• Practice saying “Yes” to these

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When Things Go Wrong Unholy trinity of

• Self-criticism • Self-isolation • Self-absorption

An Anidote: Self-Compassion • Self-kindness • Common Humanity • Mindfulness

Self-Compassionate Letter • Describe something that makes you feel badly about yourself • Think of loving, accepting, imaginary friend • Write a letter to yourself from your friend’s perspective ---Kristen Neff

Components of Anxiety Befriending Fear: Treating Anxiety Disorders

• Physiological  Psychophysiological arousal

• Cognitive/Affective  Future oriented thinking, fear  Accurate and inaccurate risk appraisal

• Behavioral  Avoidance and rituals

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Toppling Forward • Most of time we’re lost in thoughts about the future • Next, next, next  Looking forward to pleasure  Dreading pain

Worry

Anticipation • All anxiety is anticipatory

• Keeps me safe • Helps me cope

• Even people in terrible present situations worry about the future

• Prepares me for what may come

Trying to Be Happy by Avoiding Anxiety • The “Diver Dan” approach to life  Phobic avoidance & constriction

• Medicating discomfort • Hooked on distraction  TV, Internet, Shopping

• Stimulation tolerance

Escape-Avoidance Learning • • • • •

Enter situation Anxiety arises Leave situation Anxiety abates Reduction in anxiety is negatively reinforcing

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Exposure and Response Prevention

Compassionate Bait and Switch • Patients want us to remove anxious feeling • Instead, we help them to increase their capacity to bear it • Changing their relationship to the experience

2500 Year Old Treatment Why do I dwell always expecting fear and dread? What if I subdue that fear and dread keeping the same posture that I am in when it comes upon me? While I walked, the fear and dread came upon me; I neither stood nor sat nor lay down until I had subdued that fear and dread.

Facing Fears • Necessary component of all anxiety treatment • Mindfulness provides support

Mindfulness of Unwanted Affect

Mindfulness in Action

• Much anxiety is signal anxiety • Fear of  Anger  Sadness  Sexual urges  Repressed/suppressed memories  Unacceptable thoughts

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For recorded meditations, visit: www.mindfulness-solution.com and www.sittingtogether.com email: [email protected]

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