thinking

Practical techniques of mindfulness


I’ve been looking around at quite a few different ways to learn and practice mindfulness. There are heaps and I realise that I’m just dipping my toe in water that has been flowing for many hundreds of years really.

If the essence of mindfulness is to be fully present, then most of us have probably achieved this at various times in our lives – that sense of ‘flow’ or the moments when body, mind, spirit and any other bits of the human self integrate without recalling the past, without predicting the future. To deliberately re-create this, especially during more challenging times, is what I want to consider today.

I mentioned a day or so ago that for some people, explaining the how and why is much less successful than plunging right in. I think I am biased in terms of preferring to understand the ‘why’ before I do things… Perhaps something that is distinctive in this therapy is the experiential elements – it really is important as a therapist to know how and to practice mindfulness, so that it’s a lot easier to explain and guide another person into it. Now I’m not the only person who has said this: Dr Chris Walsh writes about this in his paper on Practical Techniques in a section called Why mindfulness instructors need their own practice. He says ‘To teach an experiential skill (to coach) requires some mastery of that skill…experiential information is often conveyed non-verbally. This can be done skilfully if the instructor carries the information at an experiential level, within the body…This makes it easier to learn by modelling, just as a rock climbing student might do with an instructor.’

So…what can we do to learn?

My first steps for myself were to learn to be mindful of my breathing. It’s an ancient zen practice to meditate breathing – to achieve complete focus only on the breathing of ten breaths. Try it now – to completely focus only on breathing in, breathing out – without distraction, without mind chatter including labelling or naming sensations, without the thoughts taking off…

Now the mindfulness part of this is to notice the thoughts wandering and gently allow them to float away while returning the attention to your breath again.

Being a very visual person, I use imagery for myself a lot – so images like the thoughts are wrapped up in a bubble, floating in the air…. or thoughts are simply blowing away from me…. or are falling onto floating leaves in a stream… or drifting down like leaves from a tree….or feathers…

Most of my images are from nature, but other images I’ve experienced using include sitting in a train, allowing the thoughts to be falling far behind as I move onward…being in a boat, watching the thoughts floating away on the wake….thoughts being part of a machine, being taken in and being processed, coming out the other side on a conveyor belt and moving far away…

I usually spend a few minutes actively ‘managing’ my thoughts using imagery, then my focus on it’s own returns to my breath.

To guide my focus on my breath, I notice my breath in my body. The cool air coming in my nose, and down my throat, becoming warmer as it moves deeper into my body – the warmer air coming out of my nose and moving the tiny hairs of my nostrils. The movement in my body as the air fills my lungs, tightening pressure on my belly against my clothing as my lungs are filled, relaxing as I breathe out. Awareness that my breath out is often longer than my breathe in, that my breathing is ‘coming from’ my belly button…

And usually I become aware that I am naming these experiences, and allow my mind to name them then return to just feeling them rather than naming them. Being gentle rather than critical, taking my time so my mind and body have no coercion or force or requirement to do anything – rather, just allowing it to occur and noticing it as it happens.

A words I associate with this practice is ‘curiousity’ or ‘inquiry’ or even ‘exploring’, but not in an active sense, just in a floating sense.

A killer for mindfulness is to expect a certain emotion, feeling or result. That’s like expecting it to be something that it hasn’t yet achieved. My preparedness to receive what happens is the key to using this process. Sometimes I do feel incredible peace and connection, other times I feel detached, or as if I’m a spectator. Still other times I leave feeling energised or ready for action, while at other times I feel ready to fall asleep. What will be, will be and what happens, happens… That is at the heart of the practice, to just allow space for something or nothing to occur, and just be.

Sometimes while sitting with an experience during this breathing practice I can feel emotions welling up (and I have seen this with other people I have coached). Again, this is something that can just be allowed to happen then subside – emotions never stay forever, unless we are trying to edit them or restrict them or focus in on them. Allowing the emotion (fear, sadness, anger, loneliness) to rise then fall so we go with it, and accept it as part of our experience, makes it less powerful and it passes on.

Distraction in the learning stages of meditating is very common. Again, I’ve used imagery for myself, other times I have just said to myself before I start that I will hear noises or feel sensations and that they are there but will just help me appreciate the moment. So I allow them to be heard, then gently return to the breath. Sometimes just being aware of the space between each sound or sensation, or distinguishing between different sensations on different parts of my body can allow them to be felt then my mind returns to my breathing.

I have used prepared scripts, pre-recorded onto CD or MP3 player, and sometimes used music (mainly ambient sounds from nature or bells). This is great initially I think, but over time it can become the focus and be a sort of prop that interferes with the process of being fully present. So perhaps it’s something to use in the beginning, but later can be used occasionally to keep the experience fresh. The mindfulness can be brought into every day activity like brushing your teeth, or getting into the car and putting the keys in the ignition, or even while washing dishes and doing laundry.
For some good examples, Chris Walsh has made some great suggestions, with references to refer to.

I particularly like Chris’s description of ‘Urge Surfing’. This is a method to reduce the ‘feeding’ of an urge by either trying to resist it, or attending to it and actually doing it. Essentially it follows exactly the same format as I’ve described above for emotions and sensations, by sitting with the impulse or urge, allowing it to build by gentle acknowledging it as a thought, then perhaps defining it, or perhaps letting our attention return to our breath and noticing any changes to the urge or sensation throughout the cycle of the breath. Chris recommends five cycles of breathing – I think it doesn’t matter how long it takes! I can see application of this in exposure therapy, and I know I have used it myself without realising that was what I was doing! You know when you really want to scratch an insect bite? And can’t? And you can allow that feeling to pass… and it does…

Finally, this is a great site with a wonderful paper by Ruth Baer summarising the conceptual and empirical features of mindfulness training. Enjoy.

And for some koan to consider as you meditate? Try these… they are ancient.

Sleep, glorious sleep – ii


In the previous post, I described some of the first areas to consider in assessing sleep problems in pain management, and discussed some simple strategies to consider. This post will complete the assessment and management approaches, and some resources you can use.

Once you have assessed sleep onset, sleep duration and quality should be assessed. That is, once someone has been able to get to sleep, how long do they remain asleep, how often do they wake, how long do they stay awake, what do they think, feel and do when they are awake. It’s helpful to ask the person to record this information, as it is for all the sleep assessment, as people are not always good at remembering what happens!

It’s at this point I often go through sleep architecture and the phases of sleep with the person. It’s normal to have periods of very deep sleep and periods of lighter sleep, and during the periods of lighter sleep it’s common for both internal and external factors to become sufficiently disturbing to bring an individual to full wakefulness. Most times this is a very brief period, but when pain is a feature it can become much longer – and it can become habitual, and maintained by poor sleep hygiene and anxiety.

As a result, it’s helpful for the person to review what is going through their minds when they wake – and for them to be advised of the way lack of distraction can make the experience of pain much more difficult to tolerate when they’ve woken during the night.

Factors known to prolong middle sleep disturbance:

  • anxiety, and especially negative rumination about ‘not being able to cope the next day without enough sleep’
  • attention, and difficulty distracting from pain while trying to return to sleep
  • using alcohol to go off to sleep
  • increasing sensory input (eg lights on, noise from TV/radio, reading stimulating material)
  • using stimulants such as coffee, tea, milo, sugar
  • moving around or exercising
  • trying hard to go back to sleep
  • remaining awake while in bed for more than 20 minutes
  • having had daytime naps (reducing the overall need for sleep at night)
  • some medications
  • nicotine addiction
  • not having skills to settle to sleep without external aids (eg needing to use a relaxation tape, typically falling asleep very quickly, not being able to relax breathing rate and muscle tension)

Each one of these potential factors can be explored and strategies employed to manage them. Most are fairly commonsense such as avoiding alcohol, coffee, leaving lights down low, using imagery or relaxation to distract and so on, but there are several that are not quite as straightforward.

Paradoxical hypnotic technique – such as trying to keep the eyelids open and saying to yourself ‘I will try to stay awake’. When the eyelids close, saying ‘I’m falling asleep now’ – this is a hypnotic self suggestion.

Relaxation techniques that do not require a recording such as breathing, counting down, progressive muscle relaxation and so on can help to distract from pain and anxiety, while providing a very low level of stimulus. If you are using a relaxation recording as part of overall pain management, it’s important that the individual learns how to do this without needing the recording once they have a solid relaxation response. If they continue to rely on a recording, it can become a habit to ‘need’ the recording, and make it difficult to use in other setting such as in bed, while driving or at work.

Positive statements such as ‘I’ll get to sleep shortly’, rolling over and saying ‘I’m dropping off now’, or ‘Even if I’m just resting I’ll be OK’ can help, as can efforts to avoid ‘watching the clock’ by, for example, turning the clock face away from the bed. These all help to reduce anxiety levels.

Some heavily addicted smokers may find using a nicotine patch at night (early in the evening) will help them avoid any withdrawal effects during the night, as some may find more than 3 hours without nicotine can be difficult to tolerate.

There are some times in a couples’ life when sleep is more difficult than others – this usually occurs with pregnancy and having children, as well as later in life with possible prostate problems. Its during these times that skills to help return quickly to sleep can be helpful for all of us! It’s useful to reflect to a couple that sleep disruption is normal, and that it’s not waking up that’s the problem, it’s remaining awake that creates difficulties. Anxiety around the thought ‘I NEED to have undisturbed sleep’ can be somewhat reduced by knowing that the brain is very good at making sure it gets enough deep sleep (Stage 4) the following night if deep sleep has been lost the previous night.

Once middle sleep disturbance has been explored, it’s time to assess terminal sleep disturbance, usually early morning waking, but also sleeping late. I ask people when they wake up, when they get up, how refreshed they feel when they get up, and how quickly they wake up.

Early morning waking can be a symptom of low mood, although sometimes it can be a feature of anxiety. Erratic bed and wake times, or napping during the day can also disrupt morning waking.

The prevalence of this problem tends to increase with age and is associated with a decreased total sleep time and excessive daytime sleepiness.

People with long term early morning awakening reach their minimum body temperature at an average time of 12:20 a.m., more than three hours earlier than a control group. Their average melatonin onset also occurs more than two hours earlier than the control group at 8:30 p.m. This results in an early average wake-up time of 4:49 a.m (Lack, et al. 2005).

Treating depression associated with early morning waking is helpful, as is sleep restriction and light therapy.

Resources:Sleepeducation.com has a large range of patient-related resources including a patient discussion forum.
Sleep restriction is a process of reducing the time spent in bed awake, while at the same time condensing the total amount of sleep in a night to a single period. There are many different ways to do this, but this description is quite clear and easy to follow.
An excellent site with a comprehensive review of cognitive behavioural therapy for insomnia is the National Sleep Foundation – worth a look, but probably mainly for patients rather than therapists.

So, I’ve reviewed some of the assessment domains and questions to ask, and some of the strategies used. If you’ve enjoyed this post, and want to get more – don’t forget you can subscribe using the RSS feed above, bookmark this site, or use Google reader to be updated. And you can comment below, or email me!

Sleep, glorious sleep


If you’ve had a new baby in your house, or been jet-lagged, worked shiftwork, or been worrying about a new job, you’ve probably had some time when your sleep pattern has really got out of sync. The feeling of not having had enough sleep is well-known to throw some of us right into depression, and sleep disturbances are one of the most common concerns of people experiencing chronic pain. It’s certainly much harder to cope with things when you feel you haven’t had enough sleep – and when it carries on, it can be very destructive, even fatal (albeit indirectly).

Sleep assessment must cover a wide range of factors that are known to influence sleep quality and quantity, and this post is an attempt to pull together and summarise those things that could be helpful to consider when talking with someone about getting better sleep.

Firstly, I ask the person about their sleep quality – do they feel like they wake up having had enough sleep, feeling refreshed. The number of hours sleep varies widely between individuals, so it’s not the number of hours of sleep that is important: it’s how refreshed the person feels that is. If they wake feeling OK, then there is little need to assess any further – and I often then ask the person why they think their sleep is a problem, if they feel fine. Usually their concerns are about the impression that if they’re not getting ‘8 hours sleep’, they are not getting enough. So a little education about the variability of sleep duration can go a long way. For some basic information, this link Healthy Sleep leads to a pdf brochure by the National Institute of Health in the US that describes basic sleep hygiene, and gives some guidance as to when a person might think about getting sleep assessed in more detail. You’ll be pleased to know this document doesn’t recommend medications!

Once I’ve established that the person is experiencing unrefreshing sleep, then it’s time to look at some basic routines. Sleep timing is dependent on various cues, one of which is the time we reduce stimulation from light, sound, and other activity. So it’s good to ask about what time the person goes to bed, what time they get off to sleep once they go to bed, what time they wake up, what time they get up, and whether they wake during the night. If they do wake during the night, it’s important to ask what they do then – especially how long they are awake for, whether they get out of bed, eat, drink, smoke, read etc. I also ask about whether the person has an alarm clock, and uses it!, and whether they sleep with another person and what that person’s routine is. At this time I also ask about napping during the day. Napping can reduce the requirement for night-time sleep, and although it’s helpful if you’re a shift-worker and needing temporary help to get through a day, it’s unhelpful in the long term because the sleep architecture can change, making achieving Stage 4 sleep more difficult.

A simple step toward normalising the sleep pattern is to ensure the person has a regular bedtime and bedtime routine, and a regular wake time and get up time. Erratic bedtimes and wake times maintain difficulties with sleep – and it’s at this time I talk about jet lag and how easily our sleep patterns alter to suit the time zone of the place we are visiting. This helps people understand that they can influence their own sleep patterns by simply changing stimulation levels and re-setting the body clock.

The next phase is to talk about sleep onset. How long does it take to get off to sleep? What does the person do as they go off to sleep? What are they thinking about? What’s happening with the temperature of the room, the light, the noise, and timing of medication.

Basic sleep hygiene deals with the need to make sure the bed is for sleep and sex only (and perhaps light reading as we wind down to go to sleep), but it’s not the place to worry, eat, watch TV, or have arguments! This is a behavioural strategy to ensure the connection between relaxing and being in bed remains intact. Keeping lighting in the room very low or the room completely dark is helpful. Turning off the TV, radio, iPod and any other stimulation will help the brain become less aroused. The temperature needs to gradually lower, but to a comfortable level, not too hot or too cold. Being hungry makes it difficult to sleep, but eating in bed and eating during the night can become habitual and re-set the metabolism. These factors are all related to the ‘body clock’ which is regulated via a paired area in the brain called the suprachiasmatic nucleii near the hypothalamus. This area responds to light via a series of neural pathways, to produce melatonin – more at night, less during the day. As a result, light is one of the most influential aspects of sleep regulation. Body temperature is also important – lower body temperature allows sleep, while higher body temperature is associated with wakefulness. Endocrine function and importantly urine production increases during the day, reducing during the night – as eating and drinking can re-set these hormonal patterns, making it more difficult to remain asleep at night. This Healthlink article is a simple description of circadian rhythms that can be used for patient education. Remember too, that medications have side effects, some of which promote sleep (eg tricyclic antidepressants), and the time these are taken can influence sleep onset. People may take medications meant to promote sleep too late in the evening ‘before bed’ – at 11.00, and find the speed of onset too gradual, and the hangover effect in the morning can be unhelpful especially when trying to change sleep patterns. Taking TCA’s earlier in the evening may be helpful – such as around 6.00pm, so that the effect is thorough by bedtime, and there is less of a hangover risk for morning waking.

You’ll see I’ve asked about thoughts and emotions while going to sleep. Long-term sleep disorder is often accompanied by feelings of anxiety, dread, and increased arousal levels as bedtime approaches because the bed is no longer associated with the feeling of relaxation and restoration. It can feel like a torture rack instead! Lying in bed awake, with the mind spinning or ruminating on negative thoughts like ‘how am I going to cope tomorrow if I don’t sleep?’, ‘I’m never going to get to sleep at this rate’, ‘I mustn’t move because my partner will wake up’ will serve to increase arousal and make it more difficult to get off to sleep.

Steps to reduce the association between bed and relaxing will help, but so is breaking any association between being awake and in bed, and worrying and being in bed. Strategies to promote relaxation include developing a bed-time ritual (cleaning teeth, getting into bed, reading a relaxing book, turning the light off, doing 10 deep breaths) can promote the relaxation response and reduce arousal. A relaxation tape, CD or even mp3 can be used also, in the short term. In the long term it’s more helpful to encourage self-regulation without an external source (partners complain about the noise of the relaxation through the headphones!).

Some techniques to stop negative rumination should be introduced if this is a problem. This can be as simple as the ’15-minute appointment with worry’ – saying to yourself throughout the day ‘I will not worry about this now, I’ll worry about it tonight when I have my worry appointment’, then worrying furiously for a complete 15 minutes from, say, 7.00 – 7.15pm. Most people can’t sustain 15 minutes of worry!! And the acts both of saying ‘I’ll worry about it later’ and writing down the worries can help reduce the emotional sting of the worries.
A further strategy can be to write a word with a neutral emotional impact such as the word ‘and’ over and over and over and over for one or two minutes can also interrupt the negative thoughts. This is helpful during the night, when it may be difficult to get back to sleep.

The strategy of getting out of bed after having been awake for more than 20 minutes, while hard to do (especially in winter!), is very effective at stopping the association between being in bed and being awake. The lights need to remain low, the stimulation from reading, eating, smoking etc needs to be limited, and once the person is ‘sleepy-tired’, they can go back to bed to sleep.

There are some other ways to help with sleep, but I’ll post these at a later date. In the meantime, these basic steps for assessing then managing sleep can be used.
Some good resources: MedLinePlus Sleep Disorders page
WebMD also has some great resources, mainly aimed at patients.
The NIH National Centre on Sleep Disorders has both patient and professional resources.

Ooops! Forgot to put in ‘How to Cope with Pain’ link to patient information tips on getting better sleep – How to get Better Sleep.

Another great place for information on all things psychological and this post on Pimping Insomnia from MindHacks.
Well, you can see there are many, many resources out there!! Must be a lot of insomniacs cruising the internet!
More will be posted tomorrow – so y’all come back now, OK?