book review

Review of “Sitting Together: Essential Skills for Mindfulness-Based Psychotherapy” written by Susan M. Pollak, Thomas Pedulla and Ronald D. Siegel.

The authors draw on their expertise treating patients and historical research to detail a gradual process of utilizing mindfulness-based therapy.

By Alicia M. Trotman, PhD

I had the sincere pleasure reading this book written by Susan M. Pollak, Thomas Pedulla and Ronald D. Sigel. New to this form of therapy, the book informed me of practices that are proving effective in healing persons with psychological illness, destabilizing anxieties and chronic pain. The authors have utilized their years of experience treating patients and have conducted substantial historical research to compile a volume that details a gradual process of utilizing mindfulness based therapy. They provide a historical basis for every practice and instructional guidelines. In addition, they include a clinical illustration to address when the practice should be used, and with whom it may be most effective. As a result, I find this book to be accessible to anyone who has a keen interest incorporating a new form of therapy or wanting to elevate their current practices with a focus on the “present.”

I was fortunate to have the opportunity to interview the first author, Susan M. Pollak, MTS, EdD.

Q. You stated in your preface that the book was intended to provide mindfulness skills to psychotherapists who may encounter different individuals that will require a practice suited to remediating their development. Since its publication, did you witness the book being helpful to other populations as well? If so, in what way?

A. While the “Sitting Together” was written for therapists, we are delighted that it is now being used as a textbook in undergraduate and graduate courses. Some professors are assigning a chapter each week to teach the fundamental skills of mindfulness, help students establish their own practice, and safely introduce mindfulness to their patients. Our hope is that “Sitting Together” will continue to be an accessible, hands-on guide for beginning as well as experienced therapists who want to bring the power of mindfulness into their clinical practice.

Q. There seems to be a mental trend that resisting discomforting memories and experiences spark their persistence. In resisting, we engage in bombastic and pleasurable behaviors to escape the pain that in reality never leaves. As a result, you mention that patients' minds “create suffering.” Thus, how does mindfulness-based therapy help a patient recognize that the pain is still present? Furthermore, when the pain is recognized, what are some common behaviors patients have consequentially engaged in to manage the pain?

A. A useful maxim in mindfulness is, “What we resist persists.” Or as many meditation teachers put it, “Pain is inevitable, but suffering is optional.” We are not going to be able to avoid pain, just as we won't be able to avoid sickness, old age and death. However, we try not to add on to the pain. For example, I am working with someone who sustained an injury while training for a marathon. Before consulting a doctor, she spent hours on the Internet diagnosing the problem, and was convinced that she had fractured her hip. She then began to worry that she would never run again, and was sure that if she couldn't run she would never be happy. Clearly, although she was only 23, her life was ruined. As we worked with this situation, she realized that not only was she anticipating the worst outcome, but also was adding emotional upset to the physical pain. As we reflected on this, she realized this was a pattern that dated back to childhood. When she saw her doctor and had an MRI, it turned out that her fears were just fears and the injury was not debilitating. One practice that is very effective for people in pain is the body scan, part of the MBSR (Mindfulness-Based Stress Reduction) course developed by Jon Kabat-Zinn. By staying with sensations in the body, bringing kind and gentle attention to them, not resisting or exaggerating them, but simply being with them, many people find that the perception of pain, along with the mental proliferation that often accompanies the pain, decreases and they subsequently have more resources to manage it.

Q. Mindfulness-based therapy involves many meditation practices. Is there yet any experimental data that show the effects these practices have on patients' ability to face painful memories?

A. This is an excellent question that brings us to the issue of traumatic memories and how to treat them. While MBI's (Mindfulness-Based Interventions) can help with symptom stabilization and reducing hyperarousal, current research suggests that the traumatic memories remain relatively intact. Researchers are now thinking of MBI's as useful adjunctive treatments, in addition to EMDR and exposure-based treatments, which can reduce re-experiencing symptoms. One excellent new book on this subject is “Mindfulness-Oriented Interventions for Trauma: Integrating Contemplative Practices,” edited by Follette, Briere, et al. (Guilford, 2014). David Kearney's chapter on working with veterans speaks to this specific question.

Q. There appears to be a heightened bodily awareness that arises as persons engage in mindfulness-based therapy. They feel the sensations from painful emotions and are able to stay with those feelings as opposed to only thought or solely “thinking about a narrative” that can be destructive to themselves and/or others without feeling. Through the therapy, have you seen patients' ability to stay with these emotions increase, and are they able to apply this skill in different situations? More importantly, when they do face a distressing situation, does ‘feeling' come before “thought” or do they work in conjunction?

A. Yes, through therapy and continued daily mindfulness practice there is often increased bodily awareness. Patients can learn to stay with painful emotions, learning to ride the waves of strong feelings. One phrase from a meditation teacher that we have found useful is, “You can't stop the waves but you can learn to surf.” Mindfulness practice teaches us is that no thought, no feeling, lasts forever. Like a wave, or the breath, thoughts arise and then pass away. Rather than shut off painful emotions that emerge during challenging situations, patients can learn to work skillfully with the thoughts and feelings that they evoke. Rather than allowing our feelings to dominate our thoughts, or vice versa, we learn to be with both. One useful mindfulness exercise that we often teach is the practice of “labelling” thoughts, available on our website. When it comes to thoughts and feelings, psychiatrist Dan Siegel puts it succinctly: We name them to tame them.

Q. Now you stated that there is a balancing act between knowing when a patient needs to stay with the narrative or the experience. I can guess patients who decide to stay with the narrative that gives rise to painful or pleasant feelings benefit from labeling which is a meditation practice that labels the experience and has been amply researched. Do you find that there are a particular group of patients based on their backgrounds/identities that gravitate more towards the narrative than the experience? Or vice-versa? Or it does not matter — each patient takes a different pathway with narrative and/or experience?

A. There is a balancing act between the narrative and the experience, and every clinician needs to find a balance that works for both patient and therapist. I have learned to be with the patient where he or she is, rather than impose my agenda. In one workshop we gave a few months ago, one participant commented, “My therapist keeps pushing mindfulness, but I just want to talk! I need someone to hear me.” Since psychotherapy is the “talking cure,” we don't want to neglect the importance of giving voice to experience so that it can be acknowledged and understood. It's always important, as in any therapy, to really listen to the patient, and not think that there's one “right” way to heal, or that mindfulness is a magic bullet that will cure all ills if only the patient will cooperate and meditate. It's always hard to generalize, but I find that patients who have experienced neglect or abuse in childhood often need to develop a narrative relationship with what happened to them, which in itself becomes an emotionally reparative experience. For most patients, it's important to start by building a strong, trusting alliance before introducing mindfulness. I think of the interpersonal relationship as the foundation of therapy, even mindfulness-based therapy.

Q. Meditation does not always work. As you stated, there are a number of reasons stated in the book where meditation practices are used as “counterproductive defenses.” Also in many of the clinical illustrations mentioned in the book, a number of patients leave therapy and then return. Do you think these defenses emerge more with persons unfamiliar with meditation? And those who are experts in mediational practices, do these defenses arise as well but with less frequency?

A. As with any type of therapy, one size does not fit all. Mindfulness does not work for every patient. Defenses and transference do not magically disappear when you introduce mindfulness into the clinical hour. Often, patients turn to meditation as a defense against trauma or interpersonal distress, seeking some refuge from the misfortunes and hardship of life. I don't think we can accurately say that defenses are greater for those unfamiliar with meditation, or less frequent in those who meditate. We have all suffered, we have all been wounded, and we all construct defenses to help us navigate through the storms of life.

Q. In part of the book it is mentioned that therapy is more an art than a science because truths become more relative than absolute when working with patients. In addition, there is a quote from Freud stating that therapy, in particular “psychotherapy”' as an “impossible profession” (Freud, 1937). It appears that there are many uncertainties, so why continue if not only for the love of the profession? There appears to be “compassion fatigue” or burnout that is experienced by some who do this work. As a result, what have been your rationales for continuing psychotherapy coupled with mindfulness practices? And for those who do have burnout, do you find that many return to the profession?

A. Therapy is often more art than science, and Freud, who advised us to turn to the works of the poets and novelists to understand the human heart, understood this well. He stated that therapy (along with raising children and governing of nations), is an impossible profession. Many therapists continue out of love of the work, and because they feel that they can make a difference in many, though not all, lives. When the work is going well, it can be enormously rewarding, and can at times feel sacred. As we discuss in “Sitting Together,” recent research suggests that what we call “compassion fatigue” may in fact be “empathy fatigue,” if caring for others is not balanced by self-compassion and equanimity. Mindfulness and compassion can help clinicians mediate burnout in the workplace.

Q. In Chapter 2 of the book, you outline the benefits of practicing mindfulness-based therapies for the therapist. It appears that the effectiveness of these therapies increase once the therapist makes mindfulness practice part of their daily lifestyle. In making mindfulness a habit, what exercises or recommendations does the clinician find most difficult?

Mindfulness is most effective when it becomes a daily practice. In talking to clinicians, one theme that often arises is the difficulty of practicing alone. Mindfulness doesn't have to be a solitary pursuit, and traditionally it was done with the support of a community. So I encourage folks to find a community of mindfulness practitioners, even if it's a virtual one, if they possibly can. And when people worry that they aren't doing it “right,” I like to remind them of something one of my meditation teachers often says, which is that you can't fail at mindfulness. Unlike academia and clinical work, where we often don't feel that we are good enough, effective enough, or powerful enough, mindfulness allows us to let go of the “comparing mind” and relax in the present moment without grasping and without needing things to be different from the way they are.

Q. Besides reading this comprehensive book, what advice would you have for therapists now seeking to learn and engage with mindfulness practices?

A. I would also suggest to therapists that they listen to talks (so many are available for free, online) from meditation masters who are also psychologists such as Tara Brach and Jack Kornfield.

Q. Besides reading this comprehensive book, what advice would you have for students who may be seeking to incorporate these practices into their educational trajectory? What resources (e.g. internships, scholarships, etc.) are available to them?

A. At this point, there are only a few programs that offer internships, scholarships or rigorous training in integrating mindfulness with psychotherapy. However, hopefully this will be changing soon. We have started a new Center for Mindfulness and Compassion at Cambridge Health Alliance, which we hope will become a model for ways to bring mindfulness into a clinical setting.

Q. Any closing thoughts?

A. People may also be interested in following my blog on Psychology Today, which has many new practices and applications that are not in “Sitting Together.”