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Part 4

Mindfulness-Based Interventions

for Specific Settings and Populations

21

Mindfulness-Based Intervention

in an Individual Clinical Setting:

What Difference Mindfulness

Makes Behind Closed Doors

Paul R. Fulton

I would like to beg you to have patience with everything unresolved

in your heart and try to love the questions themselves as if they

were locked rooms or books written in a very foreign language. Don’t

search for the answers, which could not be given to you now, because

you would not be able to live them. And the point is, to live everything.

Live the questions now. Perhaps then, someday far in the future, you

will gradually, without even noticing it, live your way into the answer.

–
Rainer Maria Rilke (1875–1926), Letters to a Young Poet

Introduction

In my teens, when I began my study of Buddhist and Western clinical psychol-

ogy, few resources were available. Most published materials were general

and theoretical, such as Erich Fromm’s
Zen Buddhism and Psychoanal-

ysis
(Fromm, Suzuki, & DeMartino, 1960),
or Hubert Benoit’s (1955)
The
Supreme Doctrine
. There was no practical literature, and like many others,

I was left to explore the territory without a map. When a group of like-

minded individuals formed a study group in the early 1980s, the idea of the

integration of psychotherapy with meditation remained mildly disreputable.

Meditation was associated with New Age self-help and exotic spirituality, and

we lingered quietly at the margins of the mainstream.

In these early efforts to integrate these two disciplines, most of the influ-

ence of mindfulness was through the therapist’s own practice, remaining

unnamed and invisible to the patient, a potent but transparent background

to the encounter. However, with the growing popularity of mindfulness,

patients are more receptive to its use
(Psychotherapy Networker, 2007).

In my own practice it is common for people already interested or deeply

grounded in meditation to seek me out because of it. While it is relatively

rare for me to recommend meditation, if I feel it is appropriate, I now do so

without the squeamishness I felt early in my clinical career. The issue of how

one introduces meditation to patients has all but disappeared.

Mindfulness has gained respectability due to the recent explosion of

published literature, much of it providing empirical support of its clinical

407

408

Paul R. Fulton

efficacy. Excellent guidance is increasingly available to new generations of

clinicians. To make such research possible, the concept of mindfulness,

derived from Buddhist practice and literature, has required refinement and

definition. For meaningful clinical trials to be conducted, it has been neces-

sary to define consistent treatment conditions, to try to isolate the “active

ingredients” in mindfulness, and control for extraneous variables. Conse-

quently, much of the available literature focuses on protocol-driven use of

mindfulness, applied in a structured manner with well-defined populations.

What is determined to be effective in a protocol-driven research trial may

not translate naturally to the individual treatment setting. What actually hap-

pens in the face to face encounter between patient and therapist in the use

these concepts and techniques? This volume provides a number of responses

to this question. In this chapter I take up the issue through case examples,

from a first-person real world perspective, learned by doing, informed by

study and (periodically inconsistent) meditation practice of nearly 35 years,

to illustrate some relatively unformulaic ways mindfulness informs the treat-

ment process.

Please note that in this chapter, my use of the term “mindfulness” lacks

a certain precision, and is offered as a kind of abbreviation for a range of

practices, perspectives, or observations gained through mindfulness practice

and study that are broader than redirection of attention or mental training.

The Continuum

As I ended a day-long program teaching about mindfulness to mental health

professionals, an elderly psychiatrist and former colleague came up to me

and asked with genuine puzzlement, “So, what
is
a mindfulness-based inter-

vention?” I was embarrassed that the answer remained unclear. The problem,

I decided, is that for all the efforts to arrive at a consistent and concise defini-

tion of mindfulness, it remains elusive for the breadth of its application. In the

clinical setting, the concept of mindfulness quickly loses precision because

its influence can be seen at a variety of levels. Describing these levels pro-

vides a kind of map to locate what we mean when discussing mindfulness.

The intersection of mindfulness and psychotherapy can be described as

occurring along a continuum. One pole of this continuum might be called

the “implicit” end, where mindfulness is practiced by the therapist, but

is otherwise invisible to the patient. Elsewhere I have written about the

“implicit” end of the continuum, describing the contribution mindfulness

practice makes to the mind of the therapist, and through it, to the therapy

(2005). Mindfulness, I argued, helps the therapist to cultivate mental capac-

ities and qualities such as attention, affect tolerance, acceptance, empathy,

equanimity, tolerance of uncertainty, insight into narcissistic tendencies, and

perspective on the possibility of happiness. The degree to which the thera-

pist’s own mindfulness practice influences treatment outcome is just begin-

ning to receive empirical attention.

Moving along the continuum, the use of mindfulness becomes more

explicit, incorporating concepts informed by mindfulness, to psychother-

apy overtly incorporating specific mindfulness techniques. Some of the

stations along this continuum are described by
Germer (2005)
as a