The Role of Mindfulness Practice in Person-Centered Therapy
This paper aims at integrating and concluding my own experience of practicing mindfulness meditation as a therapist and discussing how mindfulness practice can enhance the therapeutic elements in the process of therapy so as to increase the effectiveness of therapy within the framework of person-centered therapy. Having been a therapist upholding the principles of person-centered therapy for nearly twenty years, I always have the difficulties to articulate the ways on how to enhance the therapeutic elements in a teachable and learnable manner. It is not until I take the course on Mindfulness Based Stress Reduction that I can really grasp the skills in a very concrete way and learn in a systematic and progressive way to attain the skills.
In this paper, I would like firstly to explore the meaning of mindfulness, to inspect different means of mindfulness practice and to outline the kinds of transformation it can bring about. Secondly, I would see how mindfulness is related to psychotherapy, in particular to the person-centered therapy and thirdly to discuss how the practice of mindfulness meditation can enhance the three core therapeutic elements as postulated by Rogers (1951), i.e. empathic understanding, unconditional positive regard and congruence.
What is Mindfulness?
Mindfulness is a kind of ancient practice dated back to 2,500 years ago based on the Satipatthana Sutta as taught by the Buddha. Satpatthana Sutta can be translated as the Sutra on the Four Establishments of Mindfulness. Sati (Sanskrit) means “to stop”, “to re-member”, and “to maintain awareness”. Remembering means to acknowledge what one already knows, to access to what has been inhibited and to reconnect all the forgotten parts (Kabat-Zinn, 1990, p.94). It also involves re-minding which means to bring all those out of our mind together under our “big mind” so that we can see the whole. Awareness means “being conscious of” or “becoming acquainted with” (Hanh, 1988, p. 28). Nin (Chinese) means holding the present moment in the heart. Mindfulness can mean pay precise attention, moment by moment, to exactly what you are experiencing, separating out your reactions from the raw sensory events. It is by separating out the reactive self from the core experience, the practice of bare attention returns the person to a state of unconditioned openness. (Epstein, 1999). It is the awareness that emerges through paying attention on purpose, in the present moment, and non-judgmentally to the unfolding of experience moment to moment (Kabat-Zinn, 2003, p.125, as quoted by Germer, 2005, p.7). Mindfulness practice, in fact, is a transformation of one’s attitude through the training of specific skills rather as a training of skills in itself.
The Principles for the Practice of Mindfulness
According to Thich Nhat Hanh (1990), there are five principles for the practice of mindfulness. First, all dharmas are objects of mind, which means “because of mind, all can exist”. The object we are observing is not independent of our mind. It is manifested from our individual and collective consciousness. That means whatever we observe is part of us and it tells us something about our self. Second, to observe is to be one with the object of observation. The deeply observing mind is not merely an observer but a participant (p.121). Only when the observer is a participant can there be transformation. Mindfulness has the function of illuminating and transforming (p.120). When the object of our mindful observation is totally clear, the mind which is observing is also fully revealed in great clarity. When dharmas reveal themselves in their true nature, then the mind has the nature of the highest understanding (p.122). Third, it is the principle of non-duality. True mind arises from mindfulness and deluded mind arises from mindlessness. Mindfulness transforms the deluded mind. It reveals the true nature of the mind rather than runs away from or abandons the deluded mind. Fourth, it is the way of no-conflict. Mindfulness is “bare observation”. We accept whatever we experience. There is no craving for or pushing away. We treat our experiences in an affectionate, nonviolent, peaceful, joyful and understanding way. Fifth, observation is not indoctrination. It is our experience. Mindfulness is to observe all dharmas without any presumed or fixed ideas. Only in this manner can the true nature of the object reveal itself in the light of mindful observation and can we get into wonderful discoveries and accurate understandings.
The Attitudinal Foundations of Mindfulness Practice
According to Kabat-Zinn (1990), there are seven attitudinal factors that constitute the major pillars of mindfulness practice. First, mindfulness is cultivated by assuming the stance of an impartial witness to one’s own experience. It is a kind of non-judgmental and open attitude to whatever experiences arises in oneself. Second, mindfulness requires our understanding that things would unfold in their own time. We cannot rush into the experience we intend to. It is an attitude of patience. Third, no moment is the same as any other. Each moment is unique and contains unique possibilities. When we track moment-by-moment experience, we need to have a beginner’s mind with a sense of curiosity. Fourth, developing a basic trust in oneself and one’s own feelings is an integral part of meditation training. It is far better to trust in one’s intuition and one’s own authority, even if we make some “mistake” along the way, than always to look outside of oneself for guidance. Our only hope is to become more fully ourselves, since it is impossible to become like somebody else. Fifth, the goal of mindfulness is nothing other than to be our self. It is an attitude of non-striving for any specific goal. Just be. Sixth, in mindfulness we maintain an attitude of receptivity to whatever we are sensing, feeling, or thinking and to accept all our experiences as they are because it is really present at this moment. Seventh, in mindfulness practice we intentionally put aside the tendency to elevate some aspects of our experience and to reject others. It is a way of letting go, of letting things be, and of accepting things as they are.
The Practice of Mindfulness
After understanding the principles and the attitudes underlying mindfulness practice, we come to the means of mindfulness practice through which we can develop and cultivate the attitudes we have discussed.
Body Scan Meditation
We would start with the bodily sensation first. The Body Scan Meditation is a powerful technique which helps us re-establish the contact with our body. It involves focusing our mind and moving our attention through the different parts of our body. It helps to develop our concentration and flexibility of attention simultaneously. During the process, our sensitivity to our bodily felt sense is enhanced. Besides, by maintaining the attitude of bare observation, we cultivate our acceptance to our bodily experiences; no matter they are pleasant, unpleasant or neutral. This, in times, can increase our self-acceptance of our body and whatever aversive sensations such as pain, itching and other discomfort. Sometimes when we have completed the whole process of body scan, the body seems to become no body as our breath flows freely through the body in a boundless way. There is no discrimination among different parts of the body.
Mindfulness Breathing is the most basic and essential skill in mindfulness practice. Our breath is the bridge between our body and mind. It is the connection between our body and our external environment. It is through the breath that there is an exchange and transformation between matter and energy. Our breath plays an extremely important role in any kind of meditation. It is the most convenient object we can focus on wherever we go, whenever we are and whatever we are doing. Mindfulness breathing can help us develop our concentration and attention. When we focus on the out-breath, we feel relaxed and learn to let go. When we focus on the in-breath, we feel energized and learn to maintain alertness and awareness (Bodhipaksa, 2003). When we breathe naturally, our breath would gradually slow down and we experience calmness and being settled. Whenever our mind wanders during the process of practicing mindfulness breathing, we would just re-focus on our breath again gently. It helps us learn how to maintain concentration and awareness despite there is a lot of distractions around us. There are basically two major ways of practicing mindfulness breathing. One is the more formal and discipline way by dedicating a specific time and adopting a specific posture in the practice, such as sitting meditation. Another is the more informal way by integrating it in our daily activities, such as the regular three-minute breathing space and the coping breathing space.
Mindfulness Yoga is a practice that helps to bridge the transition from “motionless” mindfulness to “movement” mindfulness. The practice of mindfulness yoga involves very gentle stretching and strengthening exercises without striving and forcing. It is done slowly with moment-to-moment mindfulness breathing and mindfulness body sensation. It is an excellent means for us to explore our body’s strength, balance, flexibility and limitations. It emphasized on starting where the body is and gently holding the posture at its limits. It generates a respectful attitude towards our body and a welcoming attitude of listening to the messages of our body. It helps to cultivate a sense of understanding how our body is, accepting and expanding the body’s limitations, and containing any bodily discomfort.
Walking Meditation is a basic and essential way of bringing mindfulness into our daily life. We are used to have a “taken-for-granted” attitude towards our ability to walk, but in fact we have to take a couple of years for us to learn how to walk. By mindfulness standing, we re-experience how our weight is on the ground and how the ground is supporting our weight. We re-experience how our legs are keeping us in balance and how our legs take turn to keep us balance when we are walking. The walking meditation helps us be sensitive and aware of the subtle movements during walking which we use to overlook in our daily life. After about ten minutes of walking meditation when one returns to one’s standing position, one would feel more balanced and centered, standing rooted in the ground just like a tree.
Mindfulness of Feelings
Mindfully observing the uprising and subsiding of our feelings is the most effective way to be in contact with our feelings. The attitude of bare attention and letting go different nature and different intensity of feelings can help to change its energy into another kind of energy. The attitude of care, affection, and nonviolence towards our unpleasant feelings can increase our acceptance of whatever feelings arise in us. When we can accept whatever feelings we are experiencing, we can then transform them into the kinds of energy which are healthy and have the capacity to nourish us (Hanh, 1990, p.73).
Mindfulness in Daily Life
All these are practical means which help to cultivate the mindfulness attitudes. In fact, every daily activity can be done mindfully when we maintain a mindfulness attitude. There is a Zen saying concluding the essence of mindfulness in daily life. We eat when we are eating, we sleep when we are sleeping and we walk when we are walking.
It is paradoxical that mindfulness practice can be transformative and healing while we maintain an attitude of non-attainment during our practice. It is not exaggerating to say that mindfulness practice can transform one’s life and one’s way of being. Here are the changes we can experience when we are committed to mindfulness practice:
² There is an increase in awareness and ability to maintain attention and concentration.
² We can maintain a non-judgmental attitude towards our self and others.
² We can be more accepting to our self, to others and to whatever happens.
² We can have more refined sensitivity and keen observation on our internal experiences such as our bodily felt sense, our feelings and our thinking.
² We can understand more clearly how our bodily felt sense, our feelings and our thinking arise and fade.
² We can have a greater sense of connectedness in our self and with others.
² We can have a sense of kindness, friendliness and compassion towards our self and others.
² We can listen more patiently in a respectful manner.
² We can maintain a sense of wonder and a beginner’s mind when we have contacts with others.
² We would view problems as challenges and look upon negativities as opportunities to learn and to grow.
² We can suspend our preoccupations and ideas temporarily more readily.
² We can trust our intuition and our internal experience with a sense of openness, that is, more ready to empirically test the reality and open to corrections.
² We can taste the essence of our experience as everlasting change and can flow with the moment by moment life.
Mindfulness appears to enhance general well-being (Brown & Ryan, 2003; Reibel et al., 2001; Rosenzweig et al., 2003; as quoted by Germer, 2005, p.11). The above transformative changes would be experienced if one is committed to the practice of mindfulness. As a therapist, I am particularly interested in how these changes can be brought into the context of psychotherapy.
How to Integrate Mindfulness into Psychotherapy
As stated by Germer (2005), there are three major ways to integrate mindfulness into therapeutic work and they are not mutually exclusive. Firstly, a therapist may personally practice mindfulness meditation or everyday mindfulness to cultivate a more mindful presence in psychotherapy. Secondly, a therapist can use a therapeutic frame of reference informed by insights derived from mindfulness practice. Thirdly, a therapist may explicitly teach clients how to practice mindfulness themselves. It is the first kind of integration and “the most implicit” (Fulton, 2005, p.55) way of training the therapist that would further be discussed in the following part of this paper.
According to Fulton (2005), most current research on mindfulness-based therapy focuses on the effectiveness of various techniques. The therapist’s own meditation practice remains quite invisible in the background. Although it is the least explicit way of integrating mindfulness into therapy, it can be quite influential because the therapist as a person is the most therapeutic agent in inducing therapeutic changes. There is no therapeutic approach that has more emphasis on the importance of the therapist as a person and the therapeutic relationship than the person-centered therapy.
The therapeutic approach originated by Carl Rogers (1951) is based on a humanistic and egalitarian philosophy. There is a strong belief and faith in the client’s capacity for self-discovery and self-direction. Individuals are seen as basically rational, responsible, realistic and inclined to grow. When Rogers first formulated his client-centered therapy in 1951, he emphasized that the therapist’s primary role is to enter into the client’s frame of reference and provide an atmosphere of empathy, unconditional positive regard, and congruence. Establishing these conditions in therapy, which are necessary and sufficient, will tap the vast resources for self-understanding and growth that individuals have within themselves. As client-centered therapy developed through two decades into person-centered therapy, there is an increased emphasis on the therapist’s congruence or genuineness as “the most basic of the attitudinal conditions that foster therapeutic growth” (Rogers, 1980). The therapist inevitably influences the process of therapy as a whole person and the therapeutic process is centered on the interaction between the client and the therapist.
The therapist’s congruence can help the therapist to have an emotional resonance or empathic echoing with the client so that the therapist can have an accurate understanding of the client. With a non-judgment and non-evaluative attitude, there is a genuine acceptance and prizing of the client. With such conditions established, the client begins to increase his/her self-awareness, to unfold a new self-understanding and to cultivate a sense of self-acceptance. Therapeutic changes would then take place which finally resulted in the client’s self-empathy. Self-empathy is a kind of respectful inner listening, with readiness to take seriously whatever signals arise internally. It is a kind of experiential knowing and an inner echo of recognition. It enables an inner communication and an integration of different selves which may be conflicting to each other before therapy.
In summary, the essence of Rogerian therapy is embedded in nondirective empathy. The foundation block of the theory is the organismic tendencies towards growth. The change agent of the therapy is unconditional positive regard.
The Importance of the Therapist’s Congruence
The therapist’s congruence means that he/she is fully focusing on the present moment. He/She is able to flow with the moment-to-moment experience of the client, that is, fully present with the client. The therapist is able to get in touch with his/her inner experience and is courageous enough to disclose the here-and-now experience if it is therapeutic to the client. The transparence and spontaneity of the therapist is also a therapeutic agent in the process of therapy. Rogers has commented in his late years that when he was “intensely focused on a client, just my presence seems to be healing” and “simply my presence is releasing and helpful” (Rogers, 1986, p.130).
The Importance of Empathy
It is the empathic attitude that is essential and not the behaviors such as the techniques of reflection of feelings, paraphrasing or worst of all parroting. It is a deep and sustained psychological contact. Yet, it is not a kind of emotional diffusion or emotional identification. It is an ability to “perceive the internal frame of reference of another with accuracy and with the emotional components and meanings which pertain thereto as an ability if one were the person, but without ever losing the ‘as if’ condition” (Rogers, 1951, p.210). It encourages the client to hold or stay with his/her experience so as to stimulate a deep re-working of personal life issues. It is a powerful “curative agent” in itself and thus a major component of the healing process. It creates a secure therapeutic relationship and strengthens a working alliance between the client and the therapist. It dissolves the sense of alienation in the client. However, empathy without sympathy (or compassion), without understanding, and without wisdom, can be harmful.
The Importance of Unconditional Positive Regard
There is no point to talk about acceptance if there is no accurate understanding of the client. With an in-depth empathic understanding, the acceptance and non-evaluative prizing of the client is very nourishing and affirming. It encourages the client’s risk-taking of contacting his/her vulnerable self. It also conveys a faith and respect in the client as a person and in his/her ability to heal. The unconditional positive regard of Rogers conveys an egalitarian attitude which strengthens the client’s autonomy, responsibility and mutuality. It is not only a caring presence but a non-manipulative and non-intrusive caring that would not reinforce the client’s dependency.
The Importance of the Therapeutic Relationship
It is a true encounter between two human beings attempting to make contact in a helping context. It provides an interpersonal support, a sense of togetherness, hope and courage for the client to face his/her conflicting and disorganized selves, and his/her denied negativities. It is a kind of non-exploitative inclusion without losing the differentiation of boundary between the client and the therapist. The dialogical and interpersonal nature of the change process is becoming more important through the process of the development of the therapy itself.
Difficulties in Person-Centered Therapist Training
It is much easier to talk about empathy, unconditional positive regard and congruence in a conceptual framework than to implement these attitudes in the therapeutic context. Rogers (1951) has only identified these as the “necessary and sufficient conditions” for therapeutic changes, but he has not provided us concrete means to attain these.
This has aroused a lot of arguments disputing these conditions as necessary but not sufficient, a lot of skill trainings on empathy which reduce this quality to a mechanical means (such as Egan, 1986 and Carkhuff & Anthony, 1979) and a lot of integration with other therapeutic tasks in order to enhance therapeutic effectiveness (such as Greenberg et al., 1993). As commented by Greenberg, Rice & Elliot (1993), the therapeutic relationship is always necessary (for providing the basis for therapeutic work), generally sufficient in the long run (i.e. curative in itself), but not always efficient (i.e. can be enhanced by task-focused interventions). However, researches have not supported the superiority of one method of therapy over another (Luborsky et al., 2002, as quoted by Fulton, 2005). “The model of therapy simply does not make much difference in therapy outcome” (Miller, Duncan, & Hubble, 1997, p.7, as quoted by Fulton, 2005). Studies have found that the most potent predictors of a positive treatment outcome are related to qualities of the therapist and the therapeutic relationship. Qualities of the therapist include empathy, warmth, understanding, and acceptance (Lambert & Barley, 2002, as quoted by Fulton, 2005). Empathy may be even more influential in intervention-based treatment than in relational-based therapy (Bohart & Greenberg, 1997) while others support that the relationship is the treatment (Duncan & Miller, 2000, as quoted by Fulton, 2005).
Hence, there is no need to have further emphasis on the three core therapeutic conditions as postulated by Rogers. The challenge is how to train therapists to attain these attributes and to enhance these therapeutic attitudes. Mindfulness practice for the therapist may provide a possible answer to this as mindfulness cultivates numerous qualities that are highly suited to establishing a strong therapeutic alliance (Fulton, 2005, p.58).
The Role of Mindfulness Practice in Person-Centered Therapy
Mindfulness in fact has a lot of commonalities with humanistic-existential approaches of psychotherapy (Schneider & Leitner, 2002, as quoted by Germer, 2005, p.22). Both emphasize “the person’s inherent capacities to become healthy and fully functioning” (Shahrokh &Hales, 2003, p.78 as quoted by Germer, 2005).
The Person-Centered Philosophy
Mindfulness practice is to look deeply in order to see into the essence of things, to see their nature (Hanh, 1990, p.35, 83). It is a gradual process of ever-increasing awareness into the inner workings of reality itself (Gunaratana, 2002, p.3). It is an attitude towards discovering the “truth” (Fulton, 2005, p.49), and aimlessness is the foundation for realization (Hanh, 1990, p.122). The essence of mindfulness echoes with Roger’s non-directive intervention. The therapist does not have a presumed goal to lead the client, but to track his/her moment-to-moment experience going deep into the client’s inner experience and aiming at an accurate understanding. This is an attitude of non-striving. The ability to suspend temporarily our own frame is based on a deep trust in the vast inherent resources and the actualizing tendencies of our clients. Rogers has once commented that the truth is always friendly.
The practice of mindfulness can increase the therapist’s self-awareness of his/her bodily sensation, feelings and thinking, and an understanding of how such experience arises. This helps the therapist get in touch with his/her inner experience during the therapeutic process. It allows us to be less reactive to what is happening. If we, as therapists, are stable, relaxed, understanding, loving, compassionate, and not caught in egotism, then the things others do and say will not have the force to produce an internal formation in us (Hanh, 1990, p.102). Hence, mindfulness can be an antidote to the therapist’s transference and counter-transference in the therapeutic process. Such “genuine fearlessness” (Germer, 2005, p.47), on the part of the therapist, helps to enhance his/her trustworthiness and reliability. The integrity and wholeness of the therapist is the most essential therapeutic agent.
Preparation for Therapeutic Contact
The wholeness of our self is the basis of any meaningful contact (Hanh, 1990, p.46). A state of mindfulness is a state of mental readiness (Gunaratana, 2002, p.165). The mind is thus clear and not burdened with preoccupations or bound in worries. I personally find that the three-minute breathing space is a very good preparation for a therapy session. It is like emptying a cup of tea so that it is ready to contain whatever the client is going to pour in it. By having a beginner’s mind, I don’t presume that my client I am going to see is the same as the one I saw last time. When we renew ourselves we see everything else as new (Hanh, 1990, p.46) With sustained mindfulness, we can maintain attention and concentration on our client without a wandering mind.
The practice of mindfulness trains the therapist to have “an impartial watchfulness” (Gunaratana, 2002, p.139) and “present-moment awareness of change” (p.140) through the awareness and observation of breathing. “It is observing the passing flow of experience” (p.141). Mindfulness meditation is a living activity, an inherently experiential activity (p.4). Practicing therapist can experience what is “nonjudgmental observation” (p.139) and “participatory observation” (p.141) which enables the therapist to be truly empathic with the client.
Unconditional Positive Regard
The impartial, non-evaluative, non-judgmental qualities of the therapist contribute to the “holding environment” (Winnicott, 1971, as quoted by Germer, 2005) of therapy. When we practice mindfulness of the feelings, we learn to greet whatever feelings come up to us, be it pain, sadness, joy or anger. This helps us, as therapist, welcome our client’s feelings more easily. Contact with and being with our emotions can be highly therapeutic. The therapist’s receptivity, containment and tolerance to receive whatever emotions of our client help to bring forward the client’s seemingly unacceptable parts. “Change is the brother of acceptance, but it is the younger brother” (Christensen & Jacobson, 2000, p.11, as quoted by Germer, 2005, p.7). The wholeness of the therapist also helps to accept the client as a whole person without seeing him/her as fragmented or compartmentalized parts.
Compassion: A Hybrid of Empathy and Unconditional Positive Regard
Empathy towards others is a natural extension of self-empathy. Mindfulness practice offers a way to change our relationship to negativities and sufferings by surrendering our need to reject it. This is an act of kindness to oneself (Fulton, 2005, p.63). When we can be really kind to ourselves, our compassion to others simply arises. When we feel at ease and at peace with ourselves, especially after mindfulness meditation, we are less likely to find faults with others. The safety of genuine acceptance is thus spontaneously conveyed to our clients (Fulton, 2005).
As postulated by Rogers (1951), change would take place when the therapist and the client are psychologically in contact. Rogers also emphasized an egalitarian relationship with the client. A downplay of the therapist’s authority and power, and the empowerment of the client is a cornerstone of the person-centered therapy. An understanding of “interbeing” (Hanh, 1990) through insight meditation tells us that we are not quite different from our clients. The sense of interconnectedness dissolves our sense of separateness and softens our heart to embrace our clients.
Only through an understanding of this nature of relationship can the therapist create the space for the client to stay emotionally present with the therapist, to stay with difficult feelings for “one more moment”, thus enhances the client’s capacity for mindful awareness of self-in-connection (Surrey, 2005, pp.94-5). The therapy process is thus deepened and enlarged. In moments of deep connection in relationship, we break out of isolation into a more whole and spacious state of mind and heart, and the interdependent nature of our existence is intuitively experienced (p.95). When we are alert and focused, energy is building up. As the therapeutic process is going on, there is a synchronization of energy between the client and the therapist and there would be a transformation of energy. Therapy is a “moving along” process (Stern, 2003 as quoted by Surrey, 2005), moving along different points of “now”. The relationship enlarges and grows in spaciousness, aliveness, freedom, spontaneity, resilience, and creative power (Surrey, 2005, p.102). Thus, relationship itself can be therapeutic.
Outcome of Therapy
The therapeutic goal of the person-centered therapy is to elicit the actualizing tendencies of the client so that he/she is a “well-adjusted” individual. The client would then be flexible, open to new experiences, resilient, richly feeling the ups and downs of life while maintaining perspective, capable of close and loving relationships, compassionate towards others, able to see things from multiple perspectives, productive at work, and aware of his/her strengths and weaknesses (Germer, 2005, pp.41-2).
In fact, healing is a transformation of view rather than a cure. It involves recognizing our intrinsic wholeness and, simultaneously, our connectedness to everything else…it involves coming to feel at peace within our self…it can lead to dramatic improvements in symptoms and a renewed ability to move towards greater health and well-being (Kabat-Zinn, 1990, p.184).
As discussed in this paper, there are a lot of similarities in the philosophy and attitudinal foundations between mindfulness and person-centered therapy. The way that Rogers presented his person-centered therapy may appear to be philosophical and abstract, without listing the therapeutic procedures that the therapist should follow or providing any concrete means to attain the therapeutic attitudes. The practice of mindfulness meditation does offer a possible consideration for the therapists to cultivate the attitudes that can nourish the qualities of empathy, unconditional positive regard and congruence.
Rogers has entitled his book in his later years as “A Way of Being” (1980) to convey that it is a way of being to be a person-centered therapist. Mindfulness is also a way of being, a way of living our moments and living them fully. It is a lifetime’s journey along a path that ultimately leads nowhere, only to who you are (Kabat-Zinn, 1990, p.443).