Key moments, in order
Consider it a medical treatment, one the patient does rather than one done to them.
Reach for it, think about it and counsel on it the way you would CBT-I or behavioral activation. Your options are not just medication prescriptions.
It has religious roots, but it is not a religiously based practice: religion was simply the organizing culture of spirituality until recently.
Marsha Linehan developed DBT out of a combination of behavioral therapy and the Zen tradition of mindfulness.
Third-wave CBT, especially ACT, is in large part founded on mindfulness.
Its clinical lineage: mindfulness-based stress reduction research in the 1980s showed it helped certain disorders and distress, DBT combined behavior therapy with Zen mindfulness, and much of third-wave CBT, especially ACT, is founded on it.
Calling yourself eclectic, or saying you do psychodynamic therapy after reading some Freud or taking a class or two, is a problem without real training in the theory, concepts and frame behind the techniques.
Three necessary and sufficient parts: deliberate attention (on purpose), to the present moment (the ongoing now, not the past, the future or what should be), without judgment. And it is a practice, something you actively do.
Without judgment includes not judging yourself for judging or for drifting out of it. It is called practice because you fail.
Keep it super simple. Skip the layers of Buddhist thought and your own experiences.
Rumination is living inside your own thinking: words, symbols and fantasies in your head, aimed at the past, the future or what could be. That self-facing state is tied to the default mode network, and paying attention to something outside you or to the present pulls you out of it.
It means stepping back and seeing thoughts as a process happening within you rather than as you. Getting closer to the observer, not the thoughts, urges and emotions that pop up, opens a little space before you respond. The CBT term is cognitive defusion.
Aim for capacity and flexibility: being able to call up a mindful state when it helps, not living in one.
Two goals: separating your experience from your own thoughts (the observing ego, the ability to self-reflect), and countering rumination, worry and inward focus by turning outward.
Short daily bursts help you understand how your mind works and give you a little more space to react to what comes up.
The key move is taking a step back and viewing thoughts not as "me" but as a process occurring within you. Cognitive defusion is the best CBT term for it.
It is not outcome-focused. Practicing for a particular outcome undermines it: put strongly, no one who does it to get better will get better, because what they are getting better from is the someone who wants to get better. Put more softly, it downgrades the experience and the benefit.
Mindfulness gets a grade A for GAD; teaching it is almost a requirement. It is an actual treatment if done right, and there are many ways to do it wrong, which is why a professional guide often helps.
We rate mindfulness A minus for major depression, but do not sell it as a cure; present it as a tool to keep from slipping into depressive episodes.
Mindfulness gets an asterisk: on its own it can harm some patients. Lean on grounding techniques instead, because mindfulness can become very stressful when your world is full of threat.
It is usually not standalone treatment. It is a major component in some conditions, inside a plan that is multimodal and personalized.
Prescribe mindfulness for complex trauma and cluster B personality, but a modified mindfulness, often closer to grounding techniques.
It will not treat mania or bipolar depression, but it is still worth teaching to people with bipolar disorder or schizophrenia. Like exercise, it helps in every patient's life, in a dose that fits that person.
Mindfulness will not treat mania or bipolar depression, but it is still worth teaching.
Mindfulness is a huge part of substance use treatment, as in many AA programs. It is an antidote: a way to be in the present moment without the suffering that requires a numbing agent.
Targeted, scheduled, regular mindfulness practice suited to the patient is a core part of long-term treatment; not teaching it robs patients of improvement. DBT came from behavioral therapy combined with Zen mindfulness, and the Wise Mind handout is especially worth introducing.
It should not be unpleasant, very effortful or a struggle. Do not thrust someone into it; it is contraindicated if they are suffering while they practice. Feeling worse during solo practice means something is probably going wrong and they need guidance.
Just enjoying things is not mindfulness. Relaxing or enjoying yourself is fine, but it is a side effect of the process.
Apps and YouTube videos are fine for a first taste, but the long-term practice should not depend on a setting or outside source.
Give a brief overview: what it is, the pitfalls, why it should help, how it might not, and the goals.
Give patients the handouts, not the skills training manual, which is too detailed for non-clinicians. The mindfulness handouts are good for most patients, not only those with a personality condition or cluster B traits.
Frame it as the long-run piece: the medications might help somewhat, but this practice is what will really help over time.
It does not have to be sitting meditation. It can be active or not, and five minutes once a week is enough to start.
Commit to one set time a week when they will not be busy, distracted or upset, rather than practicing at random.
Do not practice above about 7 or 8 out of 10 distress. There are different skills for that, such as the DBT TIP skills, and you do not want the practice tied to distress in the patient's mind.
Have them try any of the exercises once and see which work best. There are hundreds of ways to practice, so help them pick one that works for them.
Judging yourself for judging is judgment too. Just notice it and put your attention back.
Used as an escape from fear or panic, it stops being mindfulness and becomes another avoidance behavior. It works the first few times, then stops working like any PRN.
Get people used to practicing when they do not need it, with a short, specific time frame and a variety of practices.
Strike when the iron is cold: practice when things are calm so it helps in stressful periods. Practice only under stress and you will be too ramped up to benefit.
Not yet confident with the material? Search "DBT mindfulness PDF" and teach from that.
For the basics, read mindfulness handout 1A with the patient: what mindfulness is, what the skills are, and what the practice is.
The three mindfulness "what" skills are observe (just noticing body sensations), describe (putting words to your experience and labeling what you observe, usually without loaded value judgments) and participate.
Describing the moment ("it's 4 a.m., I've been sleeping for six hours") can help you calm down, even though calming is not its purpose.
Describe is a little riskier for ruminators, but it is very individual, so offer a buffet of skills.
Introduce Wise Mind (handout 3), especially to patients on the borderline spectrum.
Follow up like CBT homework: what it was like, what got in the way, whether they scheduled it, whether they keep a calendar.
When they did try it, take a neutral, curious stance so they do not feel they had to enjoy it. Reorient toward long-term change, the way an SSRI is not supposed to make you happy right away.
Before you check in, say that most patients do not follow up on the recommendation, so no worries.
You cannot get to the right treatment without the right diagnosis or formulation.
Each moment is a point made in the episode, linked to the second it was said. The topic links open everything the podcast has said on that topic.