Give patients a workout in the ‘ego gym’ with mindfulness exercises

Mindfulness has become an impor­tant supportive psychotherapeutic intervention for a variety of psychi­atric conditions,^1-3 regardless of what other modalities the psychiatrist employs (eg, phar­macotherapy, other psychotherapeutic inter­ventions). In general, mindfulness involves engaging in meditation exercises, analogous to working out in the gym, to strengthen “mindfulness muscles.” These exercises increase the patient’s ability to remain in the moment, “as is,” and without judgment.

I think of mindfulness exercises as an “ego gym” for the patient as he (she) gets to exercise the ego functions of agency, atten­tion, awareness, acceptance, and empathy. Advising and helping patients to be present and exist with their thoughts is a psycho-educational approach and form of advice consistent with principles of supportive therapy. In this article, I provide a practical framework for doing and teaching mind­fulness using the mnemonic BREATHE.

Flow is more important than sequence
The 7 elements of mindfulness exercises contained in BREATHE do not need to be done in order. Rather, mindfulness gener­ally involves each of the following elements flowing, or tumbling, into each other, not standing as a distinct entity.

Being in the now, “as is,” without judg­ment (eg, being present/being vs doing; Buddhist origins; diaphragmatic breath­ing/body scans; “breathing-space” medi­tation exercises). In general, mindfulness meditation exercises focus on some sen­sory experience (eg, the physical sensa­tion of breathing or of a difficult emotion, or sounds and smells in the environment). Some mindfulness meditations are called “body scans.”

A patient can shift his (her) focus during mindfulness meditation to a sound or some other stimulus intruding on his original meditative focus, such as an intense emo­tion or pain, that might arise and become the new focus of mindfulness meditation. Ideally, mindfulness exercises are done without the intention of achieving anything (ie, there is no “striving” for anything when being mindful). Striving, after all, is doing; mindfulness is being.

R(AIN). Mindfulness, as operationalized by Kabat-Zinn,⁴ starts with a focus on breath­ing similar to many meditation practices in Buddhism. When the patient wanders into intense emotions, such as suffering, that become the focus of mindfulness, use the mnemonic-within-a-mnemonic RAIN as a guide; typically, this involves first anchoring with a few deep breaths, and then becoming mindful by:
• Recognizing (and labeling, nam­ing, “tagging”) the emotion (eg, sad, hurt, angry, embarrassed); this engages frontal lobe processes that diminishes amygdaloid limbic system overactivity¹
• Allowing (ie, accepting suffering)
• Investigating, with an open and curious attitude, using one’s senses to experience, feel, and explore thoughts and emotions
• Non-identifying with one’s thoughts, feelings, emotions, or suffering (expressed in the important mindfulness refrain: “You are not your thoughts or emotions. You are the entity that simply is aware of them.”).

Experiencing. The patient stops at the perceived experience or sensation and does not automatically react with thoughts, emo­tions, distress, or judgments. Mindfulness is a psychotherapeutic intervention that is “more experiential than cognitive.” Encourage the patient to stop at the “door of experience” and not enter the doors of thinking, emotion, and feeling.

Accepting without judgment—also called “awarenessing” or “avoid avoiding.” This involves being aware of the experi­ence regardless of what it entails, whether suffering, thoughts, emotions, or pain, and not trying to escape or avoid the difficult experience. Psychodynamic principles help us understand how psychological defenses designed to avoid the experience of the “unbearable affect” often lead to more problems for patients. In mindfulness, only avoiding is to be avoided.

Thoughts. People tend to over-identify with their thoughts and emotions. In mindfulness, you emphasize to the patient that (1) he is not his thoughts or emotions and (2) these cognitive processes do not represent facts.

Heartfulness—or, healthy, happy, free from harm. Mindfulness from the Buddhist tradition also includes “heartfulness” and “loving-kindness” and the development of compassion and kindness for one’s self and others. Mindfulness meditation there­fore also involves development of loving-kindness/compassion toward oneself and others—even one’s enemies (eg, “May I be healthy, happy, and free from harm.”). I have found this aspect of mindfulness useful for patients who feel angry or entitled, with characterological problems.

Empathy for others. As an extension of, or further emphasis on, loving-kindness, medi­tation focuses on understanding the suffer­ing of others. In certain monastic practices, this mindfulness meditation involves “tak­ing on” the suffering of another.

Disclosure
The author reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.