#78042: Integrating Mindfulness into Clinical Practice

Thich Nhat Hanh, Zen Buddhist author, teacher, and often referred to as the father of mindfulness in the West, states [1]:

Nhat Hanh's manual The Miracle of Mindfulness, published in 1975, lays out the basic principles of what he calls "engaged Buddhism" [1]. These guidelines first appeared in a long letter of support and advice to a fellow Buddhist monk during the Vietnam War. Writing from exile in France, Nhat Hanh wanted to encourage young Buddhist students in the social work school he founded in the 1960s.

Refusing to align with any political group, these social workers and students were kidnapped, imprisoned, and killed. It was during this time that Nhat Hanh urged them to continue to work in a spirit of compassion and of reconciliation, to not give in to despair. He emphasized the essential discipline of following the breath and cultivating calm mindfulness, of staying aware and present in the moment [1].

Although mindfulness has been practiced for many centuries by Buddhists and other spiritual traditions, its use as a therapeutic tool in Western medicine is a fairly recent phenomenon. Since the 1970s, several mindfulness-based clinical approaches have been developed and have inspired a wave of scientific and scholarly investigation.

In Western medical practice, mindfulness is described as a psychological state, a practice of mindfulness meditation, and a mode of awareness. The current understanding of mindfulness in clinical psychology is that mindfulness is an awareness of experience in the moment, without judgment, and with acceptance. However, it is important to note that acceptance is not a passive, docile, or hopeless state—it means experiencing an event without having an extreme reaction and without suppressing it [2].

Interest in mindfulness started in America with the growth of Zen Buddhism in the 1950s and 1960s. Psychotherapists began to integrate meditation techniques into their practices, and researchers experimented with ways to heighten awareness and explored levels of consciousness, including through drugs and meditation [3].

One of the most famous of these researchers was Dr. Richard Alpert, who became known as Ram Dass. He was a psychology professor who worked with Dr. Timothy Leary at Harvard University in the 1960s. Their controversial teachings on the use of lysergic acid diethylamide (LSD) and other psychedelics for expanding consciousness and achieving spiritual awakening are well known in the field. Ultimately, Leary and Alpert were dismissed from Harvard and mainstream academia.

Whether working these exercises oneself, or teaching them to clients, it is important to remember the word "practice." No one can be ideally in the moment the first time she or he tries these exercises. As with learning any activity, mindfulness takes practice, especially in order for it to become internalized and a more automatic part of daily living. It is especially important to highlight the practice element with clients, because many clients abandon an activity if they do not experience instant results.

It is normal for clients not to experience an effect right away, which is why starting with a three-minute goal is important. In addition, it may be advisable to teach at least three different mindfulness skills at first, because one usually resonates most strongly in terms of causing a positive response. If a person can find a core skill to work with initially, then he or she may be encouraged to start working with some of the others.

The challenge of mindfulness is that, while it seems so simple on the surface, practicing it can be quite challenging. This is partially because Western society is the very essence of mindlessness—fast-paced and result-oriented, with a focus on "doing" rather than "being." As Kabat-Zinn articulates, the work of mindfulness is some of the hardest work in the world [7].

The history of Kabat-Zinn's stress-reduction program, which came to be known as MBSR, and its teaching protocols are explained in his book Full Catastrophe Living: Using the Wisdom of the Body and Mind to Face Stress, Pain, and Illness[5]. This book is considered a classic in the area of mind-body medicine. While Kabat-Zinn was unlikely the first professional to use mindfulness principles with clients and patients, the results of his program generated attention within his own medical center. MBSR then expanded into the psychological and medical fields at large, cementing his status as a pioneer of modern mindfulness.

It is important to remember that mindfulness practice and MBSR are not synonymous [10]. MBSR programs must follow the eight-week protocol and ideally be presented by an individual who received training directly from Kabat-Zinn and his team. The MBSR structure contains work in breathing, seated meditation, walking meditation, gentle yoga, and body scanning. Participants are encouraged to practice these skills as homework, and the hope is that over the course of the program, changes in attitudes toward oneself and one's health will change.

Most of the mindfulness research available at present is related to formal MBSR and MBCT, also a systematized program that uses mindfulness practice to help people readjust their negative schema.

Comprehensive meta-analytic research demonstrates a strong effect of the completion of a formal MBSR program on overall psychological well-being, especially in clinical populations [11]. The same review found that general mindfulness meditation practices outside the scope of a systematized MBSR program have the strongest effect for subclinical populations, especially connected to the attitudes of mindfulness and wellness variables. The increased effect sizes for MBSR could be related to the components of the program that are not directly tied to mindfulness meditation [11].

MBCT is a fairly new approach that combines cognitive-behavioral techniques with the mindfulness skills of MBSR. It was originally developed as a treatment of recurrent depression and has been used for several years in the treatment of depression with good results. MBCT was developed by Segal, Williams, and Teasdale, with the first clinical trial published in 2000. Since then, scientific evidence indicates that MBCT may also be effective in the treatment of other conditions such as bipolar disorder, anxiety, food and eating issues, and psychosis. Like MBSR, the MBCT protocol calls for an eight-week course during which participants learn how to use cognitive methods and mindfulness meditation tools to combat the processes that trigger depression. Better understanding of the association between thoughts and feelings and how to interrupt and change these processes to achieve better mental health are at the core of this therapeutic technique [12].

A meta-analysis to determine the efficacy of MBCT to prevent depression relapse confirmed that the approach had positive results, especially for those with more severe symptoms [13]. One study explored whether MBCT was superior to maintenance antidepressants and found MBCT to be as effective as medication in reducing re-occurrence of symptoms—both MBCT and medication had positive outcomes [14].

Other very popular clinical approaches within the helping professions make use of mindfulness principles in their foundational philosophy. While many have been influenced by the contributions of Kabat-Zinn and his work with MBSR, there is recognition that MBSR's structure may be limiting when working with certain populations in certain clinical settings.

Dr. Marsha Linehan is best known for her development of the ground-breaking therapy DBT, which is now a first-line option in the treatment of borderline personality disorder. Linehan found that the discipline of behaviorism was not enough to create change in patients with suicidal ideation or attempt—a population that has tried multiple times to change without success. DBT is based on two core principles [15]:

DBT is based on the philosophic principle that two things can be true at the same time. This important concept is used to change the black-and-white thinking that defines borderline personality disorder and other personality disorders.

Also, in working with patients with borderline personality disorder, traditional cognitive methods are often missing the necessary component of self-soothing or regulating affect. Linehan found that mindfulness and other meditation strategies worked well to fill in many of the gaps in the cognitive approach. DBT addresses this need with its focus on emotional management and regulation in treatment. Traditional DBT involves a combination of techniques including mindfulness, cognitive-behavioral therapy, relaxation, and breathing exercises [15].

Popular DBT skills that are especially rooted in mindfulness include "radical acceptance," or total acceptance of an experience or situation over which one has no control without trying to change or resist it. Other similar mindfulness concepts used in DBT include "turn the mind" (to accept and to simply be) and "letting go" (to detach from outcomes). It is very common for DBT to be taught in the form of skills groups, recognizing that clients or patients should learn and cultivate skills for tolerating intense affect and practice how to apply them [15].

To date, DBT is the most well-researched treatment for borderline personality disorder and is considered to be a first-line treatment by many clinical entities [16]. The most consistent finding is that DBT is effective in reducing parasuicidal behavior in patients with borderline personality disorder. In addition, these studies found a reduction in anger behavior and better social adjustment. There are also promising research results for DBT with patients with eating disorders and elderly patients with depression [17].

Another popular approach in the helping professions today is ACT, developed by Stephen Hayes and his team in the late 1980s. This modality also blends traditional cognitive analysis strategies with mindfulness principles. Two popular acronyms used to summarize this approach are FEAR and ACT [18]. Distress is caused by FEAR:

To address this maladaptive response, the healthy alternative is ACT:

ACT has been suggested as a promising approach to treating PTSD and other trauma-based mental health issues. The approach has six core ACT components: creative hopelessness, the problem of control, willingness and defusion, self as context, valued living, and committed action [19].

Further reading in ACT is recommended for those looking to blend mindfulness-approaches with cognitive-behavioral work. As an approach, ACT has a great deal of empirical validation to date [15].

Although MBSR, MBCT, DBT, and ACT are the most popular modalities in modern psychology that relate to mindful practice, there is evidence of mindful practice in many other approaches to psychotherapy and helping, even if mindfulness does not seem to be presented as a major focus.

For instance, some may have been introduced to the benefits of mindfulness through eye movement desensitization and reprocessing (EMDR) therapy. Francine Shapiro, who developed EMDR in 1987, was a student of mindfulness and wove many mindfulness concepts into her EMDR protocol [8]. In EMDR, the client is invited to just notice or observe something, such as a thought, a body feeling, a memory, or an emotion, without judgment. Where so many approaches to therapy confront irrational beliefs or promote analysis, mindfulness approaches in therapy encourage clients to just notice [8].

Even 12-step programs of recovery introduce concepts like living in today (as opposed to projecting to the future or dwelling in the past) and practicing acceptance as a pathway to peace [20]. Many newer approaches, like DBT and ACT, contain elements of 12-step recovery, which traces back to the 1930s. Newer approaches add to the tradition by teaching the path to mindfulness instead of just telling people to live in today or practice acceptance. A hallmark of trauma-informed addiction treatment is not just to rely on slogans and platitudes, but also to work with clients on learning how to put these helpful ideas into practice [21].

In oncology settings, mindfulness training is often offered through MBSR or mindfulness-based cancer recovery. These are usually eight-week programs with weekly meetings and home practice of mindfulness techniques and yoga exercises. Issues addressed include loss of control, uncertainty about the future, depression, anxiety, fatigue, pain, and sleep problems.

A 2017 review of 13 studies of various cancer types found consistent positive effects for anxiety, stress, depression, and overall quality of life [22]. A few studies have shown that mindfulness training has greater improvement than other interventions, such as nutrition education and expressive group therapy, and with more long-term sustained benefits [22].

Reflection

Think about your existing paradigm, or approach, to psychotherapy. How might you weave some mindfulness principles into what you already do?

There is a vast amount of scholarly research on the use of mindfulness-based interventions in mental health and general health care. In 2012 alone, more than 500 studies were published demonstrating the positive impact of mindful practice on recovery from a wide variety of mental health, addiction, and physical disease conditions. According to Shonin, Van Gordon, and Griffiths, a definitive conclusion about all mindfulness research is difficult because of the imprecise parameters with operational definitions (e.g., some programs have structured protocols, like MBSR and MBCT, whereas others, like DBT, ACT, and mindfulness-based relapse prevention [MBRP] therapy, make use of mindfulness strategies as part of their larger scope) [23].

Another problem exists, at least for the more scientifically minded, in reconciling the precisions of empirical language with the more imprecise, spiritual concepts often used in mindfulness writing that may not lend themselves to specific empirical measure. Nonetheless, Shonin, Van Gordon, and Griffiths conclude that [23]:

A proliferation of research and writing has also emerged addressing the changes that occur in the human brain during the practice of mindfulness. In a 2011 article, Kabat-Zinn summarizes the findings [7]:

The Department of Veterans Affairs recommends offering mindfulness-based therapies for patients with chronic multisymptom illness and symptoms consistent with fibromyalgia, irritable bowel syndrome, or myalgic encephalomyelitis/chronic fatigue syndrome.

(https://www.healthquality.va.gov/guidelines/MR/cmi/VADoDCMICPG508.pdf Last Accessed: September 11, 2023)

Strength of Recommendation: Weak

A 2015 meta-analysis involving 21 studies found that eight regions of the brain consistently changed in experienced meditators [24]:

While research into mindfulness and meditation is in the early stages, their findings suggest that mindfulness practices are promising in the treatment of clinical disorders as well as supporting better mental health and increased well-being for the general population [24].

This section will present some additional breath work ideas to work on alone or with clients, building on the foundations of diaphragmatic breathing. Be advised that in the traditions of yoga and mindfulness meditation, there are many more breath exercises to attempt if they are proving useful. Additional resources for breath work techniques and instructions are provided at the end of this course. Whichever specific breath strategy works best, the key when incorporating breath work as a practice in mindfulness is to develop the habit of focusing totally on the breath. The goal is to breathe with single-pointed attention and focus, no matter how much practice it takes to get there. Cultivating this practice makes deeper breathing a more automatic, healthy response in daily life when one is met with a stressor.

The practicing awareness strategy introduced earlier in this course is a form of meditation. Mindfulness meditation is about being in the here and now, however it is practiced. By strict definition, meditation is extended thought, reflection, or contemplation. Contrary to popular misconception, meditation is not about erasing thoughts, but about learning how to be with them more effectively. The word meditation comes from the same Greek root as the words mediate or medicine, which simply imply bringing order back into natural balance.

If one is open to it, meditation can also be carried into a more dynamic plane of movement and exercise. The ancient practice of yoga is one of the primary components of traditional MBSR. However one practices yoga, whether it is part of a structured MBSR program or as part of a personal fitness and wellness regimen, it is a physical and mental practice that can help cultivate mindfulness.

Yoga is a Sanskrit word meaning union, or more specifically, to yoke. A yoke is a device for bringing two parts together. In yoga, the yoke is the spiritual realm, bringing together body and mind. In psychotherapy and the helping professions, attention has been focused on the importance of holistic care and integrating the human elements of mind, body, and spirit. The practice of yoga is designed to create this union and has been doing so for thousands of years.

In the 1970s, the conscious dance movement began on the West Coast. This approach promotes the gathering of people to dance in a "come as you are" format. Conscious dance classes are not focused on learning specific steps, but rather encouraging dancers to connect their breath to movement in a mindful way.

One such approach is dancing mindfulness, which draws on research from mindfulness work and trauma competency, using the art of dance as the primary medium of discovering mindful awareness. Participants are encouraged to access their body's healing resources while dancing through seven primary areas of mindfulness in motion: breath, sound, body, story, mind, spirit, and integrated experience, with a respect to the attitudes of mindfulness [8]. A small study of women who engaged in a dancing mindfulness practice found improvements in overall health and well-being and growth in emotional and spiritual domains [43].

In Western culture, especially in the United States, eating is often done automatically or while distracted, and this mindless eating has been linked to obesity and gastrointestinal problems [44]. One solution is to practice mindful eating, an approach used by many eating disorder and weight-loss programs to help participants reorient their relationship to food. The art of mindful eating includes:

Mindful eating, like other channels of mindfulness, requires practice. Popular food items for completing this exercise include almonds, raisins, and dark chocolate. MBSR, for instance, makes use of raisins as its instruction method. One can also use an item that comes with a wrapper for extra sensory dimensions [8].

Not feeling heard or listened to is one of the great causes of distress in humans today. This suffering is no surprise when a culture is heavy on talking and slim on actually listening.

To become a better listener, actually making time to practice listening is paramount. In Western culture, music and sounds are more background noise than anything, almost like a soundtrack for fast-paced multitasking. Teaching (and practicing) mindful listening can help build listening skills and be used as a valuable stress reliever.

One of the most powerful lessons of mindfulness is a resistance to multitasking. This is reflected by a simple approach to everyday tasks. For example, if you are going to do the laundry, really do the laundry. After everything presented so far in this course, consider what this might mean. One of the core lessons of mindfulness in daily living is to be in the moment for every task, giving it total focus. So, for instance, when one is doing the laundry, this will capture one's sole attention, instead of having other projects going on as well.

Those in the high-pressured, multi-tasking generation are likely to fight this wisdom. Yet, in practice, they will often find that staying focused on the task at hand results in less stress. The idea of practicing mindfulness in every activity of daily life can serve as a means for stress relief and overall wellness; living in this manner is a worthy point to discuss with clients. Be prepared to process or coach through any resistances that may come up, because doing the tasks of the day in a mindful fashion can seem impossible to clients at first. As with teaching any mindful practice, it is imperative to advise clients to start small and avoid getting frustrated if the practice is not immediately conquered.

Reflection

Think about one of your activities of daily living that you seem to do on autopilot, like doing the laundry, brushing your teeth, or cooking dinner. The next time you do that activity, do it with single-pointed concentration and notice what happens for you. Practice the art of mindfulness in daily living. Try it for at least one week with three different activities.

It is very common for beginning helpers to struggle with the concept of silence, interpreting it as a sign that they have done something wrong or that the session has stalled due to their incompetence. However, with practice, one will find it is in the silence where clients do their best work. When words are removed, even for a moment, tremendous insight can emerge. Giving a client permission to be silent, to just sit with something (e.g., a thought, a feeling, a body sensation), is a solid technique. If there is a silent halt in a session, one should honor it and encourage clients to be comfortable when silent and still with their experience; the session will move on when it is supposed to.

This is a way to subtly interweave mindfulness into work with clients. Silence is one of the microskills of counseling that is inherently mindful, and it is one of the simplest ways to integrate mindfulness into clinical work, regardless of one's primary orientation. Giving clients the permission or encouragement to be with that silence and notice what comes up in a non-judgmental way transforms the potency of the skill. The following is an example of how this might play out in a session:

Client P is 26 years of age, a White gay man who is in counseling for issues connected to depression and low self-esteem. He and his counselor have just engaged in an emotional discussion about his father's non-acceptance of his sexual orientation and choices that he has made about his career. The session has gone silent, and by practicing the skill of attunement through reading Client P's nonverbal communication, the counselor chooses to invite the silence.

Counselor: It's okay. You don't have to say anything right now. Why don't you just sit with the silence and notice whatever may come up in you? Don't censor whatever you may get; just go with it.

Client P: (takes a breath) Okay.

For the next several minutes, the two sit in silence, with only the sound of both of their breathing patterns audible. Client P expresses a series of winces and eventually starts to cry.

Client P: Sad. I'm just really sad.

Counselor: Okay, sad. Let's not judge that sadness, P. Just be with that feeling; don't judge it.

Too often, clinical work gets stifled because, just like modern society, counselors and clients think that there must always be something to say or think about. Therapy has come to be associated with analysis and breaking things down, a place clients come to be called out on their dysfunctional thought patterns and behaviors. While these can be important features of therapy, their excess can thwart the emergence of emotional or somatic material that needs to come to the surface in order to be cleared. One intervention that may be used to counter this tendency, regardless of the modality used in a session, is to invite a client to just "sit with" an emotion, a word, or a somatic experience. Giving her/him permission to just be with something without an internal critic can make room for movement within the session, especially movement of the insight-oriented nature.

Reflection

How comfortable are you with silence in your clinical sessions? What barriers may exists that keep you from being comfortable with silent moments?

Mindfulness approaches may be incorporated in treatment planning with a variety of conditions commonly encountered in clinical work. In general treatment planning, a three-tiered structure that is seen as a consensus in the literature, especially when it comes to addressing trauma- or stressor-related disorders, may be followed.

Stage one begins with stabilizing the client and preparing him or her for deeper healing work. The teaching of coping skills and affect regulation techniques is a vital component of stage one work, and this is an ideal time to begin the introduction of mindfulness strategies for coping.

In stage two, the client is assisted to more deeply process emotional disturbances or issues that he or she is stuck on, blocking optimal health.

Finally, in stage three, reintegration, the client takes the skills that he/she has acquired as part of their therapy into life following termination.

Although the revised fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) contains a category of trauma- and stressor-related disorders separate from anxiety disorders, for the purposes of discussing clinical mindfulness, anxiety and trauma may be examined together. Not all trauma meets criteria for PTSD. The term "trauma" is from the Greek word meaning wound, and clinically significant trauma may be conceptualized as unhealed emotional wounds that continue to cause functional impairment. In some cases, the result is a PTSD diagnosis, but other times the unhealed wounds manifest as other diagnoses, including anxiety, depression, and adjustment disorders.

In many cases, approaches effective for the treatment of trauma triggers are also effective for the treatment of addiction cravings and responses. As discussed, there is a connection between unresolved trauma and addiction responses because it is a natural tendency to practice avoidance (one of the specific criteria of the PTSD diagnosis) when viscerally threatened. Self-soothing with an instantly gratifying chemical or behavior is a sure way to calm the body, but the escape is only temporary, and for many, the vicious cycle escalates. However, a full discussion of the intricacies and debates of trauma-addiction interaction is beyond the scope of this article.

G. Alan Marlatt, a major figure in the area of treating addictive disorders, and his colleagues developed MBRP, an approach designed as an aftercare program following primary addiction treatment that follows a flow similar to MBCT, with specific focus on relapse prevention [45]. The major goals of MBRP are to:

Even when not using MBRP's specific protocol, the goals for therapy with recovering addicts are similar. The coping skills developed for both trauma and addiction are centered on working with body-level responses and practicing self-compassion. The definition of non-judgment provided previously in this course essentially outlines the mindful approach in working those in recovery. Similar to work with trauma, addiction work can begin with teaching the following coping skills with a mindful focus:

When working with body cuing during recovery, it is important for clients to begin noticing and describing not only how stress manifests in the body, but how to work with how cravings manifest in the body as well. The following is a script that one can use as a guideline (modified and personalized) to help a client identify his or her cravings and address them in a healthy way using body cuing.

Bring to mind your drug of choice or whatever stressor makes you want to use your drug (or behavior) of choice. Spend a moment being totally aware of that drug or stressor. Notice any sensory details you may notice about it. What does it look like? Does it have any other sensory details, like a sound or a smell? Just notice, non-judgmentally, anything that is connected to this drug or stress.

Take a moment to notice what is happening in your body. There are no right or wrong answers; just notice whatever you may notice. Maybe you feel something in one particular area of your body or maybe you feel something all over. Whatever it is, just honor it and be with it. If whatever is coming up in your body had a color, what color would it be? If it had a shape, what shape would it be? Maybe it has a texture. Maybe it has a sound or a smell. Whatever it is, just notice it and pay attention to it.

Now I would like you to think about one of your healthy coping skills—maybe breathing, working with your muscles, or getting up and taking a walk. Ask your body what healthy outlet it most needs right now. Then, honor your body by engaging in that healthy coping skill and notice what happens. Whatever skill you choose, remember to breathe mindfully and fully throughout the exercise. Just keep noticing what happens.

Learning to listen to one's body and train it to respond in a healthy way is a prime skill for recovering addicts to foster, as the body will give clues before one's mind consciously recognizes an issue. Mindfulness is about responding to stress instead of reacting to stress. A Kabat-Zinn axiom is that while one cannot stop the stress of life (or in this case, the cravings of addictive responses), one can learn how to surf the stresses [6].

A common saying in mindfulness-based classes is that anxiety is about living in the future and depression is about living in the past. The solution is to develop a practice of living in the present moment. However, this can be difficult. In working simple mindfulness strategies with depression and conditions related to unresolved grief, the primary goal is to help a person become more present-focused even while exploring unresolved trauma from the past.

As discussed, one strategy for interweaving mindfulness into a session is to begin and end with three minutes of mindful breathing (of the client's choosing). Even if cognitively oriented methods are used for processing, incorporating this simple breath work will prepare the brain for the work.

A common complaint with depressive disorders is poor energy or motivation. Clients may express mental fatigue, saying "My head hurts from thinking so hard," or "These thoughts running around in my head just will not stop." Mindfulness techniques such as energetic massage and guided imagery can be used to help energize or reorient a client [8].

A Note About Grief

Grief is a normal part of the human experience that, if not adapted to sufficiently, can lead to functional impairments. Many clinicians are rightfully tentative to pathologize grief. In the DSM-5-TR, there is a special note in the depressive disorder diagnosis criteria cautioning professionals that some expressions of grief may manifest as clinical depression, and in these cases a diagnosis can be made. Professionals are advised to use their discretion about what constitutes a depressive episode compared to, in DSM-5-TR terms, a typical grief response [46].

However, some find the terms "typical" and "normal" to be problematic clinical constructs. Worden favors the term "adaptation" when describing how people respond in the aftermath of a loss, indicating that one will never be the same after a loss and recognizing that certain people will adapt more healthfully to the experience of loss than others, based on a wide variety of individual and situational variables [47]. These variables can include the nature of the relationship, the value placed on what was lost, an individual's internal resources for coping, and frames of reference for meaning-making and/or spiritual integration of the experience.

Although not a solution for every client, mindfulness strategies can be helpful for many struggling to adapt in the aftermath of a loss. These approaches can be applied in whatever combination will best help the individual more fully embrace the foundational attitudes of mindfulness, especially acceptance, trust, and letting go. The simple strategies covered throughout this course can help an individual endure the proverbial waves of grief when they come.

In some cases, coping with grief is made more difficult by the internal judgments that clients experience, often in reflection of others. Shame obviously plays a significant role in addiction and trauma, but it can be just as significant in complicated grief presentations when a person feels he or she should somehow be over the experience. A mindfulness practice can provide individuals with the tools to deal with whatever emerges emotionally in a non-judgmental manner. Resultantly, the adaptation becomes more effective and ultimately healthier.

Reflection

If you have experienced issues with depression, anxiety, trauma, or addiction, what worked best for you in terms of healing? Looking back on what worked, could any of these activities be described a part of the mindfulness spectrum covered in this course?

Reintegration, the third stage in the three-tiered model for trauma processing, is about equipping clients with the skills they need to live life healthily and happily. Although certain exceptions may apply for clients with chronic mental illness, in general, the goal is to help a client work through his or her issues and adopt the necessary skills to no longer require regular therapy—a lifestyle change.

Exploring wellness resources available in the community is an imperative part of reintegration work. If a client mentions following through with a recommendation during therapy (e.g., yoga, dance, community meditation group) and finding some benefit, he or she should be encouraged to continue. Although clients may not need therapy for the rest of their lives, everyone can benefit from support, especially support that comes from a community of people who are focused on wellness.

The first step in identifying local mindfulness resources is often a simple Internet search. Because MBSR, as a structured program, has shown results in promoting psychological well-being, make a point to find out where those programs are offered in the local community. In addition, many socially conscious yoga studios offer at least some classes as sliding scale or donation-based in order to bring programming to those who may need it most. Some Veterans Affairs hospitals offer free yoga classes for veterans and their families, and some programs are available in inner city areas to teach yoga and meditation to underprivileged youth.

Reflection

On the Internet, go to a search engine and enter terms like "MBSR" or "yoga," paired with the name of your city or region. What are the results? Are you willing to try these opportunities or attend the classes before sending your clients there?