How not to 'Fix' the problem: mindfulness in the therapeutic relationship

As therapists, often we miss key indicators and predictors for good clinical outcomes. It's the resistance clients feel towards change, and sometimes the lack of compassion they have towards themselves and their suffering. If we are truly interested in alleviating human suffering, there must be a fundamental shift in the way that we relate to patients' problems.

It is common to traditional cognitive behavioural therapy the agenda of change, via a clarification of life values and personal goals, and in that, we can easily fall into the trap of our clinical formulation of patients' problems and the urge to "fix" the problem. Although it could be agreed that change is central to our work, we must not allow the 'fixing' of symptoms tighten our vision and restrict our sensitivity for working with patients' pain.

For example, a patient that complains that he is unworthy of self-compassion, that he is failure; and on the other hand a striving therapist that wishes to help, with good intention, to alleviate the "symptom", i.e. the lack of self-compassion. The therapist uses guided discovery well, it brings the patient around the bend to arrive at different points of view. The therapist questions the meaning of not being worthy of compassion. And frustrated therapist explains what compassion is, and works out with patients the costs and benefits of using and not directing compassion towards themselves. The list goes on. What we see here could be described as a classical scenario in the therapy room. In the one hand we have a desperate patient looking for a solution. On the other hand we have a therapist striving for certainty and decision. In the end, both patient and therapist start giving up. The therapeutic process becomes dull, the relationship weakens, as hope vanishes and finds its way feeding patient's hopelessness and his feelings of being unworthy.

Not being mindful of this process has a profound cost to the patient's life. Without bringing a meta-awareness to what is happening, no foundation for change can be obtained. The foundation for change, in cases like this, is not in the "solution finding", but in the actual nature of the problem. What I mean by that is not a merely justification, or worse, the intellectualization of what the problem is and how it affects patient's life. That is acknowledged very well by both parts. By problem I mean 'the problem'. Therapists hooked by the idea of change, must slow down, and zoom into patients' resistance, and invite patients to bring their own willingness into their struggle, into their lack of self-compassion. Guide patients into noticing how that resistance, pain and struggle is expressed in the body, thoughts, feelings and breath. By taking this mindful approach, therapists address one fundamental daemon in this whole story: avoidance.

Patients don't come to a therapy service with little avoidance. As a matter of fact, avoidance and control is what they do best. We must observe in them. In how they avoid their pain, and thus interrupt healing and transformation to occur. And I mean transformation of body, mind and heart. This means practically, that by staying with patients in their pain, without trying to solve it, fix it, or anything of the sort, or worse of trying to give meaning to it, or extract some meaning from it, we will be doing patients a lot of good.

Recently there has been a lot of development in this area, and behavioural treatments have been focused on rediscovering the power of mindfulness in the therapeutic relationship, so to foster radical change in psychotherapy. A recent book by Kelly Wilson ('Mindfulness for Two') explores the dynamics of 'problem solving' and 'experiential avoidance' in the therapeutic relationship, and I would recommend as a good manual for clinicians wishing to integrate elements of mindfulness in their work with patients, and understand a bit more clearly about acceptance and commitment therapy and behaviour analysis.

So what can we learn with mindfulness in the therapeutic relationship and the increase of patient's awareness?

A few points stick to mind, inspired by Kelly Wilson (2009):

LISTEN FOR VOICE QUALITY: recognizing in patient's voice the pleading, whining, demanding, being pressured, etc.
LISTEN FOR PACE: What's your patient's pace when the conversation is easy? or when the conversation gets hard? Hesitation? Pauses?
LISTEN FOR CADENCE
REPETITIONS IN CONTENT: What for emergence and re-emergence of topics, and their relative inflexibility
RECOGNIZING PATTERNS IN PHYSICAL PRESENCE: is breath slow, deep, regular, deep, shallow? Constrained, fluid?
REPETITIVE MOVEMENTS: nail biting, fidgeting, clenching of jaws, and other behavioural cues. Are there times these are more pronounced/intense?
POSTURE
EYES

Some tips of how to be mindful of process and key moments in patient's behaviour in therapy.