Some people in Western cultures have preconceived notions of mindfulness as being linked to a specific religion or practice. The reality is that mindfulness can be practiced through a variety of outlets. Mindfulness is not only a meditative technique; it also includes yoga stretches or postures as a way to energize and relax the body. Yoga in and of itself has many mental and physical health benefits. Furthermore, mindfulness can be practiced while engaging in a variety of activities, such as walking, eating, dancing, singing, or in making the simple choices of daily living. The practice of mindfulness comes from the Eastern concept of smriti, a Sanskrit word meaning awareness, or in a more nuanced translation, to come back to awareness.

As a meditation practice, mindfulness is Buddhist in its origins. In fact, mindfulness is considered to be the heart of Buddhist meditation. However, Kabat-Zinn and others who write on mindfulness continue to reiterate that there is nothing exclusively Buddhist about practicing mindfulness. It is a universal approach that can be practiced alongside other philosophies, religious traditions, or even in a secular sense. One can be totally aware and in the moment with Christian or Jewish practices, with facets of nature, or with secular elements of living. If one keeps an open mind and applies the concept in the context of his/her own worldview, mindfulness may be healing [8].

According to Kabat-Zinn, there are seven primary attitudes that may be acquired and further cultivated through the regular practice of mindfulness [7]. These attitudes are non-judging, patience, beginner's mind, non-striving, trust, acceptance, and letting go. Consider what each of these attitudes mean and how each attitude may apply to overall wellness for professionals and clients.

Being non-judgmental of one's internal processes is at the heart of mindfulness practice. Non-judging refers to thinking, feeling, or responding without the influence of an internal sensor or critic. Non-judging is an attitude of "just noticing" thoughts, emotions, or whatever may surface as relevant. Non-judgment, however, does not endorse behaviors that put oneself or others in harm's way. For instance, consider a recovering addict who is experiencing an intense craving to use a substance following a stressful day. Non-judgment does not advocate that the person should just go out and use, which would certainly be harmful. Rather, non-judgment encourages the person to just notice the craving, pay attention to it, and be with it in a spirit of non-judgment.

Mindfulness, especially if practiced regularly, helps us to become more patient with ourselves. Patience, which derives from the Latin root (patientia) meaning to undergo, suffer, or bear, is the art of deferring gratification. Patience teaches how to wait with grace. By cultivating this attitude, one can not only learn to defer instant gratification, but also to be gentler with oneself when shame-based responses attempt to sabotage. Thus, mindfulness practice is a way to retrain maladaptive cognitive and emotional responses while being gentle with oneself.

The mindfulness attitude that can significantly impact this retraining of the brain is "beginner's mind." Beginner's mind is approaching each new task with an open mind. Think of the sense of wonder that a child attempting a task for the first time may experience. With this attitude, one can remove an expert's mindset and refrain from living on metaphorical autopilot. Skills like walking meditation are wonderful strategies to work with beginner's mind because one is challenged to take an activity that tends to be automatic, like walking, and break it down to appreciate each individual part as if one is walking for the first time.

The next attitude is acceptance, or coming to terms with reality no matter how harsh or unpleasant it may be. Practicing acceptance can be a pathway to peace, and it does not imply one must "like" the reality in order to discontinue fighting. Acceptance is internalizing the attitude of "it is what it is." Finally, there is the attitude of letting go, or releasing one's "grip" on a situation, emotion, person, thing, or outcome. Letting go generally results in a freeing response (or at least the beginnings of one). This response can clear the path for wellness and growth.

According to Kabat-Zinn, these seven primary attitudes are the foundational fruits of mindfulness practice [7]. By internalizing them, a variety of other attitudes can flow into our lives. Kabat-Zinn identifies friendliness, gratitude, gentleness, curiosity, non-attachment, non-reactivity, happiness, and creativity as possible outcomes. Others can include attunement, persistence, confidence, and willingness. Attunement, or being in harmony with another human or entity, is an especially vital skill for helping professionals. By practicing attunement, professionals are able to more effectively read a client's nonverbal signals and sense any subtle shifts in energy or relational dynamics.

In many of his books on mindfulness, Kabat-Zinn recalls meeting a master of Chan (a school of Chinese Buddhism) who espoused, "There are an infinite number of ways in which people suffer. Therefore, there must be an infinite number of ways in which Dharma is available to people" [7]. The English translations of dharma from Sanskrit are numerous, but the one that seems to most resonate for the purpose of helping others with suffering is to think of dharma as the stability and harmony of the universe [9].

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.

Several therapeutic approaches have been developed based on mindfulness meditation precepts. Approaches like mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT) have gained prominence. Other innovative approaches to therapy, like dialectical behavior therapy (DBT) and acceptance and commitment therapy (ACT), make use of mindfulness in their approaches. Indeed, all of these approaches are part of the larger umbrella of mindfulness-based interventions.

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.

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].

For clinical counselors and helping professionals strongly committed to meeting clients where they are along the journey, the wisdom of Kabat-Zinn's Chan master is sage guidance: Just as there are many ways that people suffer in this world, there are many ways to overcome suffering. Mindfulness is universal, and working with clients on mindful practice is a trial-and-error process to help them find the avenue or avenues that will work best to help them stay in the moments of life. There are several mindfulness outlets that people can use in combination to help bring about overall lifestyle change.

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.

When breath work is incorporated into clinical practice, it should be one of the first areas covered. In order to be effective, it should become an essential part of one's routine. Giving one's brain some time each morning and each evening to receive deep, mindful breaths is like metaphorically brushing your teeth or washing your face; breath practice delivers the brain the proper oxygen it needs to clear out and balance. This metaphor can be shared with clients to explain the value of regularly practicing breath. Committing to 3 minutes of breath work per day, working up to 10 minutes, will initiate changes in functioning and provide the practitioner with a reachable starting goal.

These three minutes may be worked on together with clients in sessions, or clients can begin practicing breath work in their everyday life, such as while waiting at a traffic light or standing in line at a store. While structured approaches to mindfulness training (e.g., MBSR) recommend longer periods of breath practice, many clients will be overwhelmed by the notion of breathing for 20- or 30-minute stretches at a time; however, 3 minutes is feasible. From a consistency standpoint, people breathing mindfully for 3 minutes at various points in the day can be more helpful, especially as a coping mechanism, than allotting 20 to 30 minutes for mindful breathing and then going on mindless autopilot for the rest of the day.

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.

There are many misconceptions about meditation, and these misconceptions can be barriers to clients engaging in the practice. Some people equate meditation with blanking the mind and believe that this can allow negative or evil influences to creep in. Others, particularly devoutly Christian individuals, may feel that meditation is specifically Eastern (i.e., only for persons who practice Buddhism). As such, one of the first steps when incorporating meditation into practice is to address any misconceptions that the client may have. Some of this bias comes from legitimately publicized meditation groups that took on cult-like characteristics (a risk with any spiritual tradition), but much of it comes from misinformation. For example, clients may be reassured that meditation is a non-denominational practice. It can be engaged in as a part of any spiritual journey, including Christianity. In fact, there are 41 references to meditation in the Christian Bible [26].

The health benefits of meditation continue to be supported by both case and research evidence. A comprehensive meta-analysis examined 163 studies of various meditation traditions (including mindfulness meditation) and found a strong effect size for meditation in helping with emotionality and relational issues and a moderate effect size for issues related to attention. The effects were similar regardless of the specific meditation tradition practiced [27].

Some people may experience a transient increase in anxiety when initially attempting meditation, as they let go of usual busy-ness and distractions and become aware of unsettling thoughts and feelings, but this is generally short-lived. In addition, mindfulness meditation and mindfulness-based clinical interventions are low-cost and low-risk mind-body practices that have been shown to positively affect quality of life and biologic outcomes in many different populations, including healthcare professionals and individuals with cancer [28].

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.

It is true that all forms of physical exercise can prove beneficial for helping with overall health and wellness. However, so many forms of sports and exercise in Western cultures are mindless and/or results-oriented. Many people in gyms watch television while walking or running on a treadmill or elliptical machine, with primarily aesthetic goals. In theory, all exercise has the potential to be engaged in mindfully, and runners have shared experiences of mindfulness and spiritual fulfillment when running [41].

As long as physical activity is focused on being in the present, without obsessing about the end result, it can be part of a mindfulness practice. However, Eastern forms of exercise like yoga, tai chi, qi gong, and the martial arts directly promote mindful attention to the physical movements and may be an easier fit. These practices can result in a heightened sense of body awareness and the associated therapeutic benefits, especially for people struggling with trauma, addiction, and eating disorders.

As discussed, some people are resistant to take up Eastern practices, even for exercise, because they somehow feel that they are violating their religious traditions (e.g., Judeo-Christian, Islamic). One response to this concern has been the development of the program Holy Yoga, which takes the breathing and stretching benefits of mindful yoga and practices them alongside Christian spiritual principles [42]. It is unclear if the wider availability of programs like these (and expansion to other religions), along with a growing body of research supporting the efficacy of yoga, will address the concerns of critics.

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:

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.

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.

If the unhealed emotional wound is what the clinician is entrusted to clinically treat, mindfulness strategies are powerful bandages in stage one work. Before any clinician can proceed with the cathartic work of reprocessing associated with healing trauma, it is important to ensure that a client is reasonably able to tolerate the emotional intensity that goes with such work. Developing a coping skills plan with an individual client is usually a trial-and-error process—what works for one client may not necessarily work for another. When helping a client devise his or her coping plan, the following strategies may be helpful:

A skill that may be helpful in the early stage of therapy for any condition, especially anxiety and trauma-related disorders, is the body cue; traditional MBSR and yoga traditions refer to this skill as the body scan. The intention is to encourage the client to begin paying attention to her or his body and to listen to the cues it gives. Whereas traditional, meditative body scans can take a very long time to do properly, use of the body cue is intended to teach clients how to check in with their visceral responses at a moment's notice [8].

It is important to coach clients to use these skills outside the office setting. It is great if a skill works in the office, but it is important for clients to put them to the test in their outside lives. If they are an inpatient or incarcerated, it is important that they test these skills when they are not with a counselor. As a stabilization approach, it may also be good practice to determine if a formal MBSR program or other mindfulness meditation program is available in the community for a client to access as an adjunct to psychotherapy. Stage one stabilization may also be a good time to explore referring a client to yoga or other wellness-based exercise programs, also as a complement to psychotherapy.

Helping clients become more mindful of their internal world during stabilization increases the likelihood that they will be able to stop if they have gone too far with processing emotional material in any given session. As such, being mindful helps with both physical and emotional safety. By beginning sessions orienting clients to what mindfulness means and how to listen to and honor the messages of one's physical body and emotional needs, clients become simultaneously aware of their possibilities and limitations.

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:

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].

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.

Originally coined by Alfred Adler, the concept of lifestyle is important to overall mental health and wellness [48]. Lifestyle is the series of choices and patterns that individuals live that are formed in reaction to early life experiences. Lifestyle can be changed at any time, an idea that is easier said than done for most. Mindful practice can play a major role in this area, especially with the focus on responding to stressors of life rather than reacting to them. If mindfulness is practiced in small ways and gradually evolves to embrace the idea that everything in life can be engaged in mindfully, the possibilities for shifts in outlook and overall lifestyle choices are infinite.

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.