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Breathing Lessons

Sitting Together: Essential Skills for Mindfulness-Based Psychotherapy by Susan M. Pollak, Thomas Pedulla, and Ronald D. Siegel (Guilford Press, 2014)

Just what is this “mindfulness,” this word Buddhists and therapists love to use, this word that’s on the tongue of the twenty-first century everywhere, this overused, misunderstood word?

The authors of Sitting Together: Essential Skills for Mindfulness-Based Psychotherapy have spent years on the question. In their book, Susan Pollak, Thomas Pedulla, and Ronald Siegel, all psychotherapists and longtime meditators, manage to be sensible and inspirational at the same time. It’s like levitating by sitting still.

They start, as we should, at the beginning. Mindfulness, the meditative “awareness of present-moment experience with acceptance,” has been around in some form for 2,500 years. Life is not easy, but it can be easier than we often make it. Even without full understanding, most therapists can recommend the benefits of mindfulness for anxiety and depression.

Yet—be honest, busy helpers—how many of us meditate? The therapist who prescribes but doesn’t practice mindfulness is like the internist who gives health advice while lighting up.

And so, the book begins with exercises that build our skills: first, in focusing attention, then in monitoring responses with neutrality (they use a lovely image of sitting by a quiet pool where “all sorts of creatures come to drink before they move on”), and finally, in acting with equanimity.

The authors understand the hazards of eager, quickly disillusioned beginners and warn us wryly about “lurching prematurely toward absolute truth.” They also understand our sheepish imperfections. There are guided meditations for distractedness (“an experienced therapist can nod, ask for clarifications … and appear to demonstrate understanding, all while planning a 12-course meal”), compassion fatigue, second-hand trauma, and even patient no-shows.

Once they’ve helped us become more calm and attentive, the authors turn to our patients, with “suggestions from the laboratory of the clinical hour.” Mindfulness-based psychotherapy rests on diagnosis, formulation, and individual treatment planning, just like any therapy should.

Here’s where their skills are truly persuasive. There are illustrations of several cases—and one breathtaking example of a long and complex trauma treatment—built on a ladder of meditative techniques they call “the art of sequencing.” Early on, their traumatized patient was unable to sit at all, so walking meditation was used. Focusing on breath was too intimate, so the patient learned to concentrate on peripheral parts of the body. Storms of emotion were overwhelming, so she practiced a meditation that allowed distance between the feeling and the feeler. Each stage of treatment was personalized with a theoretical frame and with exercises.

The patient climbed the ladder unsteadily, and in so doing, grew steadier. “Ladder” is my improper metaphor, though, because there is no top step. “Termination,” the writers point out, “is a bit of a misnomer, for …work on oneself never ends.”

Free downloads and handouts are available at the end of Sitting Together, heartfelt signs of a desire to help. A warning to skeptics: there is also a chapter that touches on the possibility of higher spiritual purposes. But this is done lightly, “If we perceive that we have moved beyond the traditional territory of psychotherapy,” the authors mull, “can we bill insurance?”

Mindfulness is nothing if not accepting. The authors realize that one response from patients, and therapists too, will be doubt. But that’s no problem. Even doubters have to breathe sometime.

Elissa Ely ’87 is a psychiatrist at the Massachusetts Mental Health Center.

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