Good morning, Dr. Malzberg.
Good morning. How's it going?
Oh, not too bad. I think I'm feeling better this episode because at the minimum, I have some gremlins or Ewoks or whatever you want to call it. Hopefully that doesn't get censored by LucasArts cheering me on in the middle of the podcast. You know, it feels good. And they're kind of like, yeah, I'm listening. It's good stuff.
We should probably explain that for the listener who doesn't listen to every single episode. There were gremlins slash Ewoks in our last two episodes.
Two or was it one? I don't know. I only heard it in one.
I do the editing for the podcasts and I don't know what I'm doing. I have no background in audio. And fixing the levels is the pebble in my shoe. I do not know how to do the levels. It's so much more complicated than... I think that's your projection. I think it's just moans of understanding. I would like to hear if people prefer having the little gremlins in the podcast or if they prefer the poorly leveled, unplugged 90s feel of the previous episodes.
Leave it in the comments.
Those are your only two options because a properly produced podcast is not one of the options right now.
Certainly not with our current user base. What is the topic today?
I believe the topic today is going to be mindfulness.
Oh yeah, big topic. I fear, again, one that people will have a tendency to neglect in our very medicalized, medicine-focused world. But I want to emphasize at the outset here that you should and can consider mindfulness to be a medical treatment. It is a treatment that the patient has to do rather than something that you do to the patient. But you should consider it as one of your treatment options.
That's a strong belief of mine.
Now, when you say it's a medical treatment, what do you mean by that?
Well, then that raises the big question of what is a medical problem, right? And we're going to go the tautological route. The medical problem in the medical model is what physicians customarily do. Okay. Whatever that is. This is not an original idea, by the way. And, um, I can't remember who it was, though. I apologize. I think it was an analytic or traditional psychiatric thinker who originated this medical model.
If you Wikipedia it, you'll find him. And then, therefore, a medical disorder is one that is found through the medical diagnostic process and is customarily treated by medicine people. That's it. Okay. And mindfulness, like anything else, is an intervention that, in my opinion, you should be reaching for, thinking about, and counseling about, similar to, for example, CBT-I or behavioral activation. Your options are not just medication prescriptions.
You should and can prescribe treatments like mindfulness.
So mindfulness can mean a whole host of other things. And it also has associations with religion, especially like Eastern religion. Can you talk a little bit about how you view it?
Yeah, I mean, that's an important thing to address at the forefront, I would say. Yeah. We can't ignore that mindfulness comes from traditional religious and cultural practices, right? Especially of the East. But I think what we should recognize and I would advocate I don't see this as a religiously based Practice, even if there is a tradition within religion. Why is that? Well, I would argue that religion was simply the organizing culture of spirituality and higher order beliefs up until very recently in human history, not that I'm an anthropologist or anything.
How did we get from traditional behavioral therapy to mindfulness? That's something that we might want to paint out. Did you ever encounter sort of the just-so story of the progression of Western psychotherapy across the 20th century? What's your take on it, if you have any?
I'm not quite sure if you're referring to something specific. I have two examples of it really coming in. There's the wonderful origin story of Marsha Linehan, who was struggling with borderline personality disorder, went and studied some Zen Buddhism and then develop DBT out of this combination of behavioral therapy and and the Zen tradition of mindfulness. And then you also see it. I think the third wave CBT, especially acceptance and commitment therapy, a large portion of that is is founded on mindfulness.
Yeah, I mean, either one is probably worth the mention, but I guess the broad strokes thing that I want to point to is that outside of the psychoanalytic realm of things you originally had the behavioralist right and again this is a just so story this is like a really broad strokes version of the history so you know it's not official but originally there are people that were modifying behaviors in the psychology community then they had the idea to bring in Thoughts, right?
Not just behaviors, but thoughts. So that goes to cognitive behavioral therapy. And of course, affect was integrated at one point in there, even though I think it's still a little de-emphasized, except as a means of analyzing thoughts. And then... Around the time in the 80s, it was I believe Kabat-Zinn and other people in this group that were researching mindfulness-based stress reduction treatments or practices, and they started to see that this was efficacious for certain mental disorders or mental distress.
and yes there was also the DBT movement as well and by the time we get past the 80s mindfulness is pretty much a scientifically established and well integrated into therapy practice Technique or set of skills, you know, so it is a broad thing. And I think as of today, it's very much separated from the religious underpinnings or rather the history. And you should just consider it as a medical treatment when you are using it in the framework of being a physician or therapist.
Yeah, there's even the specific modality of mindfulness-based cognitive therapy, NBCT. But I agree in terms of how I think about practicing psychiatry, not that I like the idea of eclectic therapists or anything, but essentially you can pick and take the helpful things from each of the different modalities and then integrate them into your practice.
Yeah, I mean, eclectic, I think is a problem because anyone can say they're eclectic, right? I'm a cafeteria therapist, or I'm a cafeteria psychiatrist, I pick and choose what's good. I mean, there's nothing wrong with that on the face of it. But I think the issue is that people may call themselves that, and they don't necessarily what's up.
And then they do nothing.
Right, they may not adequately consider or have knowledge about the basic theory and concept and the frame of how these kinds of different techniques and therapies are utilized. So that's kind of, this hopefully will be a little episode that's a primer, but it's by no means completed.
So let's jump into it so that people do have an idea of these things. Talk to me, what is mindfulness?
So this is another umbrella term, just like schizophrenia is an umbrella term, bipolar is an umbrella term, you know, mental health is an umbrella term. So keep that in mind. Lots of things say their mindfulness. I want to make a very constrained definition of mindfulness here because I think it has all the necessary and sufficient conditions that will help patients get better or at least have less distress.
So for me, I would say that there are three necessary and sufficient parts to mindfulness practice. So it is a practice. It is something that you do. Okay, actively. Not just something that you experience, not just something that is done to you as the subject. But part one is deliberate attention, paying attention on purpose. Okay, part two is to the present moment. Okay, it's deliberate attention to the now.
the ongoing now, not the future, not the past, not what could be, not what could not what should be. Okay. And then part three is without judgment. Okay. And that includes not judging yourself for judging or falling out of a mindful state while you're trying to practice it. And there's a practice is practice because you fail, right? That's why we call it practice. So again, deliberate attention to the present moment without judgment.
I think you talked about this, the three parts in a previous podcast and then I started using it because it's such a helpful way to explain it that's very simple and easy to remember. When I explain things to patients, it needs to be super duper simple. You don't want to add all these other layers of Buddhist thought and your own experiences of mindfulness because it can be too confusing and complicated and the way you put it here is just super duper simple.
Now, Can you give us a little bit more color as to what you mean by these three things? So is this something that I do all the time? Is this something that I pick a few minutes to do? Why am I doing this? When you say mindful, why is attention to the moment full of mind?
Yeah, you know, not getting stuck too much into terminology, I think we can highlight why this is important, right? Let's just take the example of anyone with any kind of ruminations. The ruminations can be trauma-related. They can be anxiety-related. They can be obsessions and compulsions. They can just be simple worries that would be common to any person, right? But if you are ruminating You are living and experiencing your own thinking, right?
You are paying attention to the words or symbols or fantasies in your head and not the outside. You are also probably focusing your attention on what could be, what should be, the future or the past. This is, generally speaking, not a particularly pleasant experience when it's kind of overdone, right? And we generally do agree that when you're doing too much of this, it's a pathological state and we have various names for it for the particular subtype in the DSM.
We should note here that we actually have some Preliminary Neuroscientific Research on this, right? And it's the default mode network. We've discovered that people in sort of self-facing, overly ruminating or introspective or depressive states seem to be in a brain state, we can call it, a brain network state, where They just have a certain activity pattern. We call that default mode network. And that is associated with certain unpleasant states or disease states.
And then when you start to pay attention to something outside of you, or the present moment, then that kind of pulls you out of the default mode network. And that's associated with other long-term changes that we're probably going to get into, unless you have something to add for that off the top of your head. I don't have it off the top of my head.
Not on that specifically, but I'll say what you said in maybe different language and just as another perspective, or I mean, probably saying the same thing, but we really think of our thoughts as who we are. And in the Eastern tradition, what they call the ego, which is different from the psychoanalytic ego, that's the idea of who I am, my likes, my dislikes. Dr. Malzberg is a psychiatrist.
He likes the color blue. He gets upset about XYZ. and our internal monologue it's always commenting on things and judging things and planning things and it contains a lot of self-thoughts like oh I like this uh this this is what I want uh I want this to go a particular way and there's especially in uh It's very common to confuse that as that that's all that we are.
And we kind of get lost in our thoughts and think that our thoughts are everything that there is to experience. And when I think of mindfulness, I think of taking a step back and instead of viewing these thoughts as me, as I, viewing these thoughts as a process that's occurring within the true me. So when I'm practicing mindfulness, experiencing thoughts is a process. And that's because we normally deeply identify with thoughts and we get sucked into the melodrama of like in New York City, someone cuts me off and it's like, oh, that jerk off.
Like this always happens to me. I'm always 15 minutes late. I just want to be on time. And you kind of get sucked into these common patterns of thinking. And when you practice mindfulness, you're able to take a step back and view these things as a process and gives you a lot more of the ability to see how our Psychiatry And then thousands of years later, we kind of just repeat the exact same things that they were saying back then, except in a scientific language.
But yeah, the default mode network is essentially that ruminative brain network when you're not doing something. You pretty much naturally start thinking of problems in the past, thinking about who you are. And that default mode network can cause a lot of problems.
Yeah, I think we should mention, though, we're not advocating that You should or should not be always in a particular state. I do think that a lot of the traditional religion aims towards that. I think that's probably wrongheaded. And really what we're looking for is capacity building and flexibility, right? You should be able to deploy a certain variety of experience or action for yourself when it is helpful to you, right?
That's what we're really getting at. And, you know, you said that you're going to say the same thing, but I think you highlighted something very different from what I was saying that is equally important. And it's that we can at least concretize two goals of mindfulness practice, if you will. One is separation. of your experience from your own thoughts and process. The ability to observe yourself, to self-reflect.
This is also captured in other terminology like egocentronic versus egodistonic or the observing ego. I'm sure There's also CVT terminology for it. Maybe it's examining your own thoughts or something like that. And then also essentially combating ruminations, worries, anxiety, and inward focus by going into outward focus. Both of these can be achieved by a more consistent mindfulness practice.
Absolutely, I am. I'm glad you bring that stuff up. I think of, like you said, mindfulness allows us to take a step back and watch the process rather than identify with the process. And I also, you mentioned like we're not trying to attain a particular state or And that's not what mindfulness is. So to me, if you were to say there's a goal It's practicing so that you can start to understand the nature of your mind and understand how it works.
And then when you practice in just short bursts a little bit every day, you have a little bit more space to react to the stuff that comes up. And you don't identify with the emotions or thoughts and you don't get sucked into them as much.
Yeah. Oh, the terminology I was thinking of that I had just forgotten was cognitive diffusion is probably the best CBT terminology for what you were referring to. Yeah. And what you're what you're talking about here, I think we need to emphasize it's not an outcomes focused Practice. If you try to practice mindfulness with a particular outcome in mind, it will subvert the efficacy of the practice itself.
The process over content mantra is just as relevant, if not acutely relevant, for this scenario. It actually reminds me of something that I wanted to figure out how to communicate in a way to interns that they would remember for four years. A lot of PGY-4s, not a lot, A minority of PGY-4s find themselves with the board exam staring them in the face a few months later, and they may not be as good at the tests as some of the other residents.
And then suddenly they're like, what should I be studying so that I can improve my board test performance? The fact is, The journey of psychiatry training is not to do a test, right? And if you're finding yourself in that situation, you may be a little late on the game. Really the best way to prep for the board exam is to put yourself fully into the practice of psychiatry and read and study and research about everything that you run into clinically across a four-year period.
And then if you're at the end there and you're just looking at a board exam, it's going to be suboptimal compared to having been in that process the whole time without targeting passing the board exam. And so it's the same thing in mindfulness. If you target getting better, having less distress, being more powerful, being more enlightened, XYZ, being a Zen master, you are not going to do as well if your target is simply, I'm going to put the effort into and practice mindfulness on some kind of a semi-regular basis.
And then I think a simpler way of putting that is that with mindfulness, no one who does it to get better will ever get better. Because what they're getting better from is the someone who wants to get better.
I don't know if they won't get better, but they will certainly downgrade their experience and the benefit.
No, I just bring in the paradox in that the... No, it's an important paradox. The person or thing that wants to be enlightened, that wants to get better, that's what we're trying to observe in some sense. So that when you do it with a particular goal in mind, you subvert the purpose in some sense. Like you mentioned in terms of just the three aspects of mindfulness, deliberate attention to the present moment without judgment.
If you have a particular goal, that's a sense of judgment. So that's not part of the process.
So, you know, if we are going to sell this thing as a medical treatment mindfulness practice, I think it makes sense to at least talk about some indications, kind of like FDA indications. If you were on the FDA board and you were going to approve some disorders for which mindfulness is indicated, which ones might you pick personally? And I don't think there are any real right or wrong answers.
This is really just personal clinical opinion.
I guess I'll go through each one and give my thoughts off the cuff. Number one, generalized anxiety disorder. To me, the ruminative loops, the anxiety, the stress about the Mindfulness is taking a step back from those things and looking at those things rather than getting sucked into them. To me, generalized anxiety disorder, I give it grade A in regards to recommendation for mindfulness. I think this is almost like a requirement for teaching for patients with generalized anxiety disorder.
Next, major depressive disorder. Similarly, I give it an A-. I think it's something that I think is really important. Part of major depression is having those negative ruminative loops, a lot of negative Mindfulness on its own is not the only... Patients can use mindfulness as a way of guilt and self-blame for why they're depressed. So I'm cautious with not selling it as this will cure your depression.
I use it as this is a tool to prevent slipping into depressive episodes, whereas generalized anxiety disorder, I think it's a standalone treatment.
Yeah. Yeah, I totally agree.
Moving on, let's go to PTSD. PTSD, I'm going to give it an asterisk because mindfulness on its own can actually be harmful to the patient. It really depends on the particular patient. Because patients with PTSD are reliving their experiences, they're very traumatic, the I focus more on grounding techniques rather than mindfulness proper because the mindfulness can become a very stressful thing when the world you're living in is full of threats and danger.
Yeah, if I may add to that for a moment. So far, completely agree. This is the same list I would have. Though for generalized anxiety, I'd pretty much make it the full primary anxiety chapter. But this gets confusing because I think a lot of even good clinicians are going to maybe sometimes label something with the primary organizer of an anxiety chapter DSM disorder when there's probably multiple things going on, right?
But yes, Anxiety, number one. Depression, pretty helpful, but needs biological treatment. I think the general thing that we have to say here is that mindfulness is usually not standalone treatment. It is a major component of treatment in some conditions, but you need to be multimodal and personalized to the patient's case. And for what you say about grounding, I actually consider grounding techniques to be mindfulness practice. There is a broad range as we're going to get into what you might consider mindfulness practice.
But yeah, I would say that for trauma disorders, what you might call complex trauma and cluster B personality, We should be prescribing mindfulness, but it must be a modified mindfulness, and you may need to do things that are basically more grounding techniques, or they're going to be different types of mindfulness. Simple, traditional, Absolutely Should I keep going with the other conditions? If you have any other major ones in mind that you want to suggest it for you.
Well, I guess what I'll say is I think – kind of jumping off what you said, I think of mindfulness as something similar to like exercise. So I think it's something that's helpful in absolutely every single patient's life. So when I say – however, when we say if it's indicated for a condition like bipolar, mindfulness is not going to treat mania. It's not going to treat a bipolar depression.
That said, it's still something worth teaching to someone who has bipolar or who has schizophrenia. However, I don't think of mindfulness as something that is helpful for the condition proper for bipolar or schizophrenia.
Yeah, that's a really good parallel. It's like exercise. It's for everyone, but it's for everyone in a different way. When I say every depressed patient gets a recommendation for exercise, it doesn't mean I want every depressed patient to be running a marathon in six months. That's not what that means. It means that for some patients, it does mean getting back to their running routine that they had last year.
But for most patients, it may mean One five-minute walk once a week or maybe even once a month, right? You need to find a goal and something that is feasible and sustainable for each individual patient. Or maybe the patient's even wheelchair-bound. It's going to be upper arm exercises or going to physical therapy. Who knows?
Our next condition in terms of grading is substance use disorder. And I'm going to give it an A there. I think... Especially you see in a lot of the AA programs, mindfulness is a huge part of treatment for substance use disorder. And a lot of it is that de-identification, the cognitive diffusion, I think, in the CDC. I want to drink, I want to take a line of cocaine, whatever the addiction is, the ability to have some Mindfulness is an antidote to being able to be in the present moment without the suffering that requires a numbing agent.
Yeah, I really like that conceptualization. I have to admit that in my mind, I didn't even think of substance use disorders because to me, I essentially lump them in the same category as cluster B. I personally have never really seen addiction without at least cluster B traits, but I know that might be a little controversial.
That's super controversial just for new listeners. Dr. Fu doesn't have the typical negative associations with cluster B that a lot of providers
Yeah, I think that kind of colors things. It's that I have a lot of sympathy and I think it's a legitimate condition that we need to recognize and treat, whereas I think many people avoid doing it because of negative feelings they have.
Yeah, because I think, unfortunately, people will hear that you said, I grew up with cluster B to be that people who use substances are jerks. And we don't think that that's what cluster B is. And that's not. Yeah, so that's an important, important caveat.
Well, then I'm going to revise and just say I've never met somebody with substance use disorder. I didn't have some kind of complex trauma.
There we go. Perfect.
Okay, I think we can move on, right? Is there any other major ones that we're missing? I think that's kind of the major categories where it would be really indicated.
Yeah, I think we covered most of the things.
Well, I guess maybe it's worth saying. I do agree with dbt in that targeted, Scheduled and regular specific mindfulness practice again titrated and geared towards the individual patient is definitely a core component of the long-term treatment of DSM defined borderline personality disorder and that if you have a patient even with strong traits and you're not teaching the mindfulness and encouraging it you're kind of robbing them of clinical improvement so you know that's a stance that I'll take anyway
Absolutely agree. And complex PTSD, I think, is also grouped in the same as there. So why don't we talk a little bit about how to teach mindfulness skills? Because I think it's one of those things we all agree mindfulness is wonderful, but a lot of providers aren't that good at teaching it. Either they're too esoteric with regards to how they teach it, or they just don't know how to.
So Yeah, talk to talk to me a little bit about how you teach mindfulness.
I guess the main thing that I want to start with is actually a warning and it connects actually to the personality and trauma group of pathologies. What should mindfulness not be? It should not be unpleasant. Okay, it should not be an unpleasant experience. It should not be significantly effortful. It should not be a struggle of some kind. Okay, so patients should not persist in any mindfulness practice that produces distress, dysregulation, or requires some kind of a significant effort other than commitment and time on their Okay if you go into the dbt skills workbook or original manual you will see a huge variety of different practices both more passive and active that are categorized under mindfulness if you go into mindfulness manuals and workbooks beyond that and act mindfulness sorry act workbooks and manuals you're going to find Tons of different mindfulness practices.
There's a traditional Indian manual that talks about a hundred ways towards enlightenment. There are so many different possible mindfulness practices. They should not be dysregulating painful or particularly effortful beyond time commitment and just actually doing it. So please keep that in mind. Don't just thrust someone into this. It's contraindicated if they're basically suffering while they're trying to practice.
Totally agree. I also want to give a caveat to the caveat that also just enjoying things is not mindfulness because I saw that a lot of just like people think mindfulness is
If you're relaxed or enjoying yourself, that's not a bad thing. It's just more of a side effect to the process. That's something to keep in mind. Another word of warning I'd like to give, I really recommend against utilizing new media as a means to practice mindfulness in the long term. Nothing wrong with using a YouTube video or a You know, app that has mindfulness practices at the beginning to get a flavor of things.
But ideally, you should be practicing mindfulness in a way that does not depend on a particular setting or external source, right? This is something that you should be capable, you are capable of doing on your own. So why don't we use this as a, let's talk about how you think about teaching mindfulness. So we've talked about the warnings and not rely on particular things. So how do you teach patients to practice it in their day-to-day life?
It might not surprise you. You've already heard it. I think that you should plainly explain these things to the patient that you're trying to teach mindfulness to. Everything that you've heard so far, people should get a general idea of what it is, hear about the perils and pitfalls, hear about why it's going to be helpful and what ways it might not be helpful and what the goals are.
So essentially what we covered, but shorter. I wouldn't get too stuck into that part though because there's one thing to explain a concept and there's another thing to actually practice it so it comes to practicing it I've tried many different things over the years but these days to be honest with you I pretty much just give them the mindfulness handouts from the DVT manual and this is again not limited to patients who have a diagnosable personality condition or cluster B traits I just think it's a very good handout
Yeah, and so it's actually a pretty big, if you just go through the whole mindfulness chapter, there's a lot there. Maybe, why don't we do a, should we try to do a role play with regards to how you would talk to a patient? I know we've talked about it before, but I always find that that's the most helpful. So would you be open to that?
I feel like it would cover too much. Let's just jump into, I've already explained everything, and then we'll do some role play, okay? How about that? I've already done the psychoeducation component.
Okay.
Okay. So, you know, for your condition, I think this is a practice that's really going to help you. The medications might help you somewhat, but I think this is really going to help you in the long run in terms of getting better. I've sent you this handout. I don't think you have a personality disorder, by the way, but DBT for borderline personality disorder just happens to have really great set of mindfulness skills in one handout that you can kind of pick and choose from.
How do you feel about trying these out before the next time we meet?
My only concern, I've tried meditating. It's just not for me.
Yeah. Now keep in mind, I don't want you to do anything that you feel like isn't working for you in the long run. And this isn't just about meditation. I'm not asking you to be sitting in place or anything like that. There are a lot of different ways you can do this. You can be active about it. You can not be active about it. All I need is something like five minutes once a week.
What do you think?
So when you say five minutes once a week, it's kind of what you were saying before of just kind of being in the present moment and not being judgmental, just like randomly throughout the day, just a random five minutes?
I wouldn't do it randomly. I actually think that can be a little challenging, at least to start. All I want is for us to commit to one time a week where you're not going to be busy, overly distracted, or likely to be too upset. Because this is not something that you should be doing when you're totally upset, okay? If you're above like a 7 or 8 out of 10 in distress, There are different skills for that.
This is going to be something kind of like upkeep or exercise. So can you pick a time once a week just for five minutes to start where you can just try out some of these exercises?
Yeah. So, okay. So I'll pick a random five minutes. And when you say some of these exercises, I'm looking through the packet you sent. There's just like, it's huge. And there's a ton of different things it recommends. Which one would you pick for me?
Well, you know, it sort of depends on your experiences that you've had before. If you've never tried anything before, I would just start with the sitting and counting or naming things around you. That's something that you can do. But as you can see, there's also not just those options, but there's even some participate mindfulness skills that you see in the package. And to start with, I would just pick any of them and try them out.
Once. See which ones work the best for you. The point is, again, just to pay attention to the here and now without judgment. And remember, if you find yourself struggling with that, and you judge yourself for it, don't worry about it. Judging yourself for judging yourself is a type of judgment too. Just notice that you're doing it and try to put your attention back on whatever it is that you're trying to pay attention to.
That's all you have to do. And after about five minutes or even less, if you feel like it's a problem, just stop and go about the rest of your week. Just try a few out, you know, maybe two or three of them in the next four weeks and then we'll meet again next time. Awesome.
Anything else you want to end before we wrap up the roleplay?
Not exactly. Here's the thing. If you try to make it too regimented, make it too official, I think that's going to raise the likelihood that it's not going to work well. So my recommendation is to be extremely casual about this. But Don't let it be a haphazard because if you don't explicitly schedule it and tell people to not use it as an escape or distress management tool, they will do that.
Because frankly, at least the first time or the first few times, it works pretty well, grounding techniques and mindfulness, to escape panic or distress. It will stop working pretty quickly like any PRN if it's used that way. Instead, we want to get people used to practicing it when they don't quote unquote need it. Right. And that's the purpose of me picking a very specific and short timeframe and having them try out different practices.
Perfect.
Yeah, and one thing I like to, when I talk to patients about this in regards to what you're kind of just saying, I say like, have you ever heard the phrase strike when the iron's cold? And then if they heard of it, essentially I'm saying that the goal of this isn't, is to practice when things are calm and easy so that it helps during the more stressful periods.
If you only practice during the stressful periods, you're going to be too ramped up to really kind of get the benefits or see it work. So I recommend working on these things, not during during times of great stress and as a goal to calm things down.
Yeah, not something I explained to the patients, but among us clinicians, you know, the general theory here is that we are trying not to associate the practice psychologically, consciously or unconsciously with distress. Right. If you need to teach distress tolerance skills, the DBT tip skills are great and you can pick other ones. If you're a fan of prescribing PRNs, I am not, you can probably do that too.
But we're trying to disengage the distress mindset from this practice fundamentally. And if you don't get in front of that, I think most people rationally will put those two and two together. So, you know, make sure those two are separate things.
Now, as we're talking about teaching mindfulness, I want to give a practical tip for new practitioners or people who aren't quite comfortable teaching it just based off of what we've heard. One thing that I do that I did early on in residency when I wasn't as confident with this material, I search DBT mindfulness PDF. Let me make sure that this is actually true. There it is.
There is a Kaiser doctor who has uploaded onto the patient portal the first, the DBT handouts from the mindfulness module, the most important module of DBT, and that's still the one I direct patients towards so I don't have to share copyrighted material. Sorry to that, Kaiser doctor. Hopefully it doesn't disappear from Google.
And because I don't have it bookmarked and I'm constantly in different rooms that don't have my bookmarks, if you just Google dbt mindfulness PDF, the first thing that comes up is Kaiser Permanente. Click that one. Then what I do usually is I share my screen. And then we walk through the particular handouts that I want to walk through. So in terms of just the basics of what mindfulness is, I would literally just read with the patient mindfulness handout 1A, which asks the question, what is mindfulness, what are mindfulness skills, and what is the practice?
And then as I've gotten more and more comfortable, I'll tailor which things I want to pick for which patients in regards to what's helpful. I also really like, I think an important one is Mindfulness Handout 4, the what skills, observe, describe, participate. I find those ones really helpful for... Quickly getting patients into the mindfulness headspace. So there it really just goes through the three what skills of mindfulness which are observe, describe, participate.
For observe, you're just noticing the body sensations. Describe You can put words to your experience and label what you observe, usually without loaded value-based judgments. So you're not trying to say, like, I'm having a bad headache. You can say that there's a I like to observe and participate once the most. Go on. Yeah, I like observe and describe the most. Participate, I think, is tough as a skill for people to practice, whereas I find observe and describe, even in my own life, actually, I have a great example of a few days ago I was having I was having I woke up at 4am and I couldn't fall back asleep and I was having all these thoughts of like oh god this I'm screwed for tomorrow and then I decided to practice the describe skills this is actually a true story because me and my wife just made the video for um the what skills you can watch on our channel and I just described like it's 4am um I've been sleeping for six hours and it actually worked really well.
It helped me calm down, which is not the purpose of it, but it did work.
I do feel that Describe is a little riskier when it comes to Ruminators. But again, it's very individual, which is why I just buffet it. I really say, look, these are listed in general and in detail in all these handouts. You look at 4A, 4B, 4C. There's so many different ideas that you can try. You just got to find what works for you. I also want people to get an idea of the Wise Mind.
um handout three especially if uh they actually are more borderline spectrum so you know to me the introduction may be important but maybe just as important or maybe
more important is follow-up because not everyone's going to actually do this after you've set that goal together right
And this is where your CBT training really kicks in. You should follow up with the patient's experience of the mindfulness, what it was like for them when they tried, or what happened that caused them not to try, even if they remembered, or did they not schedule at all, do they keep a calendar at all, all the basic CBT homework stuff that you might have learned or can't.
And if somebody tells you that they did try it, I think it's very important for you to take a neutral and inquisitive stance to get their genuine experience of it, right? We want to review with the patient and make sure That there isn't some kind of a false sense that they had to have enjoyed it or felt that it was beneficial instead of stupid or waste of time.
You want to process those emotions and reorient towards the major purpose of the mindfulness practice, which is long term change. Just like the way we counsel patients on that, you know, this SSRI is not supposed to make you feel happy right away. Uh, you know, this is something that's gonna make it easier for you to change and improve over the course of months if you stick to it.
We should be saying the same thing about mindfulness. Uh, people can and do get immediate benefits, but that's sort of like the little bit of sedation on these proof. It's not the main treatment effect.
Yeah, and I think an important part of checking in is also, I find especially with any sort of recommendation I make, I always like, before I check in on it, I always go like, and by the way, often most patients don't follow up my recommendation. So no worries at all. If, if, if you Yeah. Yeah.
This took longer than I expected to explain all these things. I had some original sense that maybe I'd touch on briefly, some other important ideas from the Buddhist tradition, but I don't know if that would be a turnoff for people.
You always love teasing us with the part two.
It's definitely not enough for a part two. I think I can cover it in two minutes.
Well, I think we're going to have to wrap up here because we don't want to belabor and have a two hour long mindfulness episode Okay,
I suppose it can be fitting into some kind of a miscellaneous you tell me type episode for which we may be overdue Well,
do you have a short pithy thing to teach us before we head off the call?
Sure, sure. I think we just don't recognize necessarily that there are traditional ideas that kind of are the best ideas that live in every culture's use of medicine. And two ones I want to highlight that you can probably see evidence throughout Okay, it doesn't Strategy that's going to work well for the person that you're working with or that the person that you are that skillful means in a nutshell the other one isn't exactly Buddhist I think it's from traditional Indian medicine but it's basically the idea of right diagnosis right treatment right you're not going to be able to get to a right treatment unless you have the right diagnosis or formulation and that's sort of the Maybe one of the major underlying features of my philosophy as a treater.
And in many of these episodes, I don't know if it's exactly Buddhist, but I thought I'd just mention it. There are many other great lessons, I think, philosophically from mindfulness traditions and other traditional cultural things, but we're happy to.
Oh, I would love to hear a full episode of this, but I won't make you do it.
I don't think people do. All right. Well, I'll see you next time.
Have a good one.