I recently stumbled upon this blog post on Health Place, explaining how mindfulness “doesn’t work” for the author. As part of the intensively trained DBT team at The Meehl Foundation, this naturally set my wheels to spinning. Before I begin explaining why, allow me to make one caveat; a disclaimer, if you will. I absolutely, unequivocally understand that every treatment option available will not work for every person. And I do not believe that you should, nor would I ever encourage a client to, continue attempting a technique that is not effective for them. However, in this one, singular instance, for this one article I feel that a large part of the puzzle is missing.
The problem – the only problem – that I see is in the application of the technique in question. Part of the reason that DBT is so effective within the target population is that it utilizes and applies a wide range of proven tactics to form a cohesive treatment modality. And while mindfulness is a part of that, the foundation in fact, it is only one part. I am sure that for a large number of people mindfulness alone can be beneficial, even life changing. Similarly, I am sure that there are some people for whom mindfulness alone is absolutely pointless. My qualm does not lay with author’s claim that mindfulness didn’t help. My concern is that a proper application as seen specifically in DBT (which I admit was not at all mentioned in the parent post) presents the possibility of greatly increasing success and decreasing suffering. After years of experience with Dialectical Behavior Therapy, when I read things like this I feel as if the author has only been shown a small piece of a much larger picture; a picture which when viewed as a whole has the potential and probability to provide greater clarity, increase the effectiveness of the techniques involved, and vastly improve the quality of life for readers navigating similar struggles.
In recent years, Mindfulness Skills™ have emerged as an important aspect of several empirically supported treatments. Dialectical Behavior Therapy (DBT) is one such treatment modality proven particularly effective in treating Borderline Personality Disorder and Bipolar Disorder. In fact, DBT is officially recognized by the Cochrane Review (Stouffer et al. (2012)) as the treatment of choice for characteristics including impulsivity, interpersonal problems, emotional dysregulation, self-harm, and suicidal behaviors; the exact same characteristics which distinguish the clients labeled as “most difficult to treat” in our current mental health system. A total of eighteen (current as of 2016) randomized controlled trials published on DBT demonstrate its utility across client groups with severe and complex disorders.
It is for this reason that I feel driven to respond to the referenced article through the lens of DBT. It’s what I know, and it is proven effective. Consider that when treated with DBT (including mindfulness), clients with Bipolar I and II and a history of recurrent hospitalization showed a trend toward decreased depressive symptoms, less fear toward and more control of emotional states, and significant improvement in several self-efficacy scales, as well as reduced emergency room visits and mental health admissions within 6 months (van Dijk, Jeffrey, & Katz (2012)). I’ve no idea what the comparable effectiveness of mindfulness alone is, but I feel those results are likely of little consequence to anyone who has already tried and been failed by mindfulness as a stand-alone treatment technique.
Mindfulness in the strictest traditional sense is quite different from mindfulness in DBT. It is true, to a certain extent that mindfulness in DBT entails, “…sitting in the moment… not worrying about the future or the past… allowing whatever emotions or thoughts that occur, simply happen, without judgement, and then allowing them to float away.” DBT, indeed, asks clients to non-judgmentally observe (be mindful of) their thoughts, feelings, and experiences. However, much like the rest of DBT, mindfulness is a process. Non-judgmental observation is only the first part of this process. Where mindfulness is the first step in DBT, non-judgmental observation is the first inch of that first step.
Most importantly, mindfulness in DBT specifically asks the client to go beyond simply observing and / or allowing events to actually participate. The goal is to develop a lifestyle of participating with awareness; an assumption of DBT is that participation without awareness is characteristic of impulsive and mood dependent behaviors. In this way, DBT teaches us to evaluate the effectiveness and consequences of behaviors and events, and act according to our goals rather than acting according to what is deemed “right” or “fair”. It empowers us to act from our goals and objectives rather than judgments. It is a tool for enabling action rather than endless rumination and suffering.
The rationale for mindfulness in DBT is empowering us to recognize and stabilize our thoughts, emotions, and experiences. To use the example posited by the author, if someone were hitting you over the head with a baseball bat, they are absolutely correct in insisting that sitting mindfully, in the present moment, and letting your feelings and thoughts go without judgement doesn’t change the impact of the bat or the pain that it causes. However, being mindful of your experience, of what is happening in, to, and around you, can empower you to notice the bat coming before it bashes you over the head, and to take action(s) to lessen the impact – at least a little.
This is the process used in DBT. Mindfulness empowers you to be consistently conscious of your cycles, to recognize that an episode is building before it spirals out of control. Once you are able to do this, you can utilize the other skills taught (distress tolerance, emotion regulation, and interpersonal effectiveness) to take actions to lessen the effects. That is the part that is missing when mindfulness is applied as a stand alone therapy.
Particularly in regard to physical pain, such as that referred to by the author, core mindfulness must be combined with distress tolerance and / or emotion regulation skills for treatment to have any real or lasting effect on the suffering caused by neuropathic pain. It is important here to note that there is a definite distinction between “pain” and “suffering”. Pain is a distressing sensation which, when functioning normally, is meant to move a person to action; to prompt them to redress or resolve the painful situation. Suffering occurs when the experience of pain is prolonged, often unnecessarily. Suffering is a subjective experience, often driven by the emotion of how pain effects the individual. Most often, suffering occurs when there is non-acceptance of the pain. The irony is that this denial of pain does not alleviate the pain, but actually perpetuates it; eventually leading from pain to suffering. Pain can be almost impossible to bear, but suffering is even more difficult.
DBT encourages a unique balance of acceptance and change. For example: In order to avoid the suffering of living with pain, you must accept that pain is going to happen. Accepting that pain is a fact of life – for everyone – allows you to stop fearing or dreading future pain, regretting past pain, or fixating on the unfairness of your pain (all things which add to pain and suffering). You then also, can take action, with clarity, to cope with or lessen your pain. You change the pain, at least to a point that it is bearable.
Mindfulness is not, and to my knowledge it never was (at least clinically), a technique for eliminating pain. Mindfulness-based pain reduction and stress reduction treatments exist, of course, but the keyword here is “based“. Mindfulness forms the solid foundation, the core, upon which such modalities are based, but it is not, never has been, and in my opinion never should be, considered the be all end all for any disorder – mental, emotional, physical, OR spiritual. Mindfulness is meant to expand our awareness, enlighten our decisions, and empower our actions. For any change – any improvement – to occur we must be aware (mindful), make a decision, and take action. And I feel that, at least from what I’ve read, those latter two steps were left out of whatever mindfulness exercises / treatment that the author experienced.
As I have said, mindfulness is a wonderful tool. And if it works for you as a stand alone treatment, I am happy you found something that works. Truly I am. But in my experience, the majority of people who attempt mindfulness as a treatment for mental wellness require a cohesive modality to achieve efficacy. So when I read about such a strong tool failing outside of such a modality – which I might add is a readily available and empirically supported resource – it makes me scared and angry for all of the people who have experienced this failure. I feel like someone needs to point out the missing pieces; to shine a light on the bigger picture, and on the possibility that whoever insists on mindfulness as a stand alone – they’re doing it wrong. I feel like someone needs to make additional information available for those who are still searching for what works. Because if it helps even one person finally free themselves from a lifetime of confusion and suffering, then it was well worth the time it took to type out this reply.