ABSTRACT
In this chapter we show how the topics discussed in this book work in action. The following case examples show how to integrate mindfulness into both individual therapy and a group. Teaching points the therapist used are in brackets, and there is a more detailed discussion of the skills used by the therapist after each scenario.
Case example: Sally
It was a foggy day when Sally set off to take her son Harry to school. Suddenly Sally was aware of a flash of white to her right when a lorry pulled out of a side road and into the driver's side of her car. A passer-by pulled her son unhurt from the wreck but Sally's legs were trapped and it took hours for the fire service to cut her free. The smell of petrol stuck in her throat and made it hard to breathe and she was terrified the car would explode.
Recovery took a long while for Sally with several operations and physiotherapy to help her walk unaided again. Sally would often cry with pain and frustration at how her life had changed and the fact she wasn't able to run and play football with Harry in the garden as she had before. Gradually the physical scars healed and Sally was able to go back to her job as a clerk in the local planning office. She worried a lot more than she had before the accident, especially about Harry. She hated it when he was away from her and was reluctant to let him go to a friend's house to play or on a trip with school.
Sally's therapist, May, suggested that learning mindfulness could help with the worry thoughts and explained that it is a way of taking control of your attention (definition of mind-fulness) so you can notice when your mind has gone onto worries and bring it back to what you are doing (linking to goals).
Sally was not convinced that she would be able to do this as her mind seemed to be caught in a constant stream of worries, but even a little relief sounded good and she was keen to try 84anything that would help. She could see her son starting to become anxious when she left him, and she did not want him to ‘catch’ her anxiety when he had always been such a confident little boy.
May explained that Sally would need to do mindfulness practices regularly between their sessions (importance of regular practice). May asked Sally to try to do the exercises without constantly monitoring how she was getting on (mind-fulness is not meant to ‘work’). Sally loved to cook and May explained that learning the skill of mindfulness was like learning to bake a cake. You need to practise and slowly it gets easier. If you are constantly opening the oven door to see if the cake is done, it will never cook properly (use of metaphor).
Sally and May started to do mindfulness practices together in the session. They began by observing a pen and using all their senses to be aware of it (mindfulness of an object). May told Sally that her mind would probably wander when she did this, but when she became aware it had, to just notice where her mind had gone and gently bring it back to the pen (normalising the actions of the mind). Sally found her mind wandering constantly and felt frustrated that she couldn't hold her attention on the pen.
‘It's a numbers game,’ said May. ‘You need to be willing to bring your mind back many times and when you do this you are being mindful.’ Sally was relieved she was being mindful and was surprised by how much she noticed about the pen that she had never taken in before, even though she always kept it in her bag and used it several times a day. ‘Not only can we notice more when we are mindfully observing but we can also pay attention to what we are doing rather than doing one thing whilst our mind is somewhere else,’ said May.
‘Imagine you are cooking tea for Harry while he is playing at his friend's house and your mind keeps going to worries about whether he is OK and wishing he were back. If you were cooking the tea mindfully you could notice your mind had gone to worry thoughts and gently bring it back to cooking the meal’ (generalising the skill into everyday life).
Sally tried this the next time Harry was out. She paid attention to the sight, smell, sound, taste and texture of the food she was cooking and found the more she involved her different senses in what she was doing, the more she could notice worry thoughts when they came up and bring her attention back to the meal.
85Sally and May began to start their sessions with a mind-fulness of the breath (mindfulness of internal environment). The first time they did this Sally noticed her breathing speeded up and seemed very irregular. She could feel her heart start to race and a sense of panic begin to overtake her. As she practised more she was able to just notice her breathing whatever it was doing.
As Sally became more aware of her thoughts she noticed how her mind would go down well-worn tracks, and labelling made it easier to notice and not act. May suggested she use the image of a luggage belt at the airport and notice the urge to take the baggage off, without acting on it. Just stand and watch as the bag goes past (use of metaphor).
Sally was doing the housework one day when her leg started to ache. ‘If that lorry hadn't gone into me it wouldn't be like this.’
‘OK, I recognise that luggage,’ thought Sally. ‘Just stand and watch the bag go past.’ Sally put her whole mind on the image of the bag as it went past her, watching it disappear into the distance. Then she put all her attention on the feel of the Hoover in her hand and the sound as she vacuumed the carpet and mindfully carried on with the cleaning (mindful participation). Instead of getting upset and angry as she would have done in the past, ruminating on the accident and how it had changed things, Sally felt proud of herself that she’d kept her mind on the task and finished the job.
Sally noticed a positive impact at work too and was really pleased when her boss commented how she seemed so much better. By noticing when her mind wandered she was able to bring it back and complete whatever task she was doing. She felt like she was in control of her mind rather than having to follow wherever it wanted to go. She remembered May telling her that when we are being mindful we do one thing at a time and that this is more effective than trying to do several things at once. She found it helped to say to herself, ‘In this moment I am filing’ or ‘In this moment I am logging the application’.
Sally noticed she felt calmer and not so jittery all the time. By observing when her thoughts were racing ahead or going into the past she was able to bring herself into the present moment. In doing this she felt her body had come off ‘red alert’ and she wasn't watching for the next disaster to strike all the time.
May gave Sally a CD with a mindfulness body scan to listen to. May's voice guided Sally through the different parts of her body and asked her to focus her attention on each in turn. Sally found this very hard at first. She wanted to avoid focusing on 86her legs because they were stiff and painful. May encouraged her to treat every part of her body the same. Not to ignore or to focus on, but just to notice each part as the spotlight of her attention came to it. Sally became aware of her whole body and that there were times when the stiffness and pain varied in intensity. She stopped trying to reject experiencing her legs and was able to be more accepting.
For Sally, part of accepting her legs as they are was noticing that sometimes she would feel sad (mindful of emotion) when the pain or stiffness stopped her from doing activities. May encouraged her to allow the sadness to come without rejecting or holding onto it. May explained, ‘This is the mindfulness skill of participation, i.e. being “in” our lives even when the experience is painful or difficult because that is the reality of our life’. May told Sally, ‘When we are being mindful we allow ourselves to have the experience and also to let it go, have it and let it go’.
Sally would often think of the mindfulness story that May told her: we are at the door of our house, and we welcome every visitor and let them in without judgement. ‘We are going to let them come and let them go. Whatever they may be: laughter, joy, sadness or pain. We treat them all the same,’ said May. ‘We are not inviting them to sit around and stay for tea, but we are just letting them in and letting them out’ (metaphor/storytelling).
