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When it comes to self-care and counseling, there is perhaps no topic discussed more than mindfulness. In fact, there are entire apps dedicated to mindfulness practice, with Calm and Headspace being two of the most well known. Mindfulness is touted as a sort of “cure-all” for all people’s issues. Too stressed? Try mindfulness. Anxious? Depressed? Try mindfulness. Mindfulness as a counseling tool is still fairly new, so there is some debate surrounding its effectiveness as a treatment. But that may soon change based on recent research. Elizabeth Hoge and colleagues, in a study published in JAMA Psychiatry in 2022, found that mindfulness was as effective as anti-anxiety medication in the treatment of anxiety disorders. In the study, participants took either a mindfulness course, which included a 2.5-hour class each week and 45 minutes daily at-home practice, or a dose of Lexapro over six months. Given the potential benefits of using mindfulness as a mental health tool for issues such as anxiety, counselors must carefully consider when and how to best incorporate mindfulness practices into their sessions.

A useful approach

Maggie Yuan, a licensed mental health counselor (LMHC) and program director at Doc Wayne (a nonprofit focused on sport-based therapy) in Boston, says that there are three tenets to any mindfulness practice: observe, describe and participate. “The first goal [of mindfulness] is to really open up the mind. It’s the practice of observing, coming into awareness and allowing that awareness to steer you in whatever direction it takes without resistance. And it’s just about noticing your thoughts and emotions,” she explains. “The second part is focusing the mind, which involves focusing attention on the specific internal states or externals impacting you.” The third part, she adds, is “just participating, trying to be engaged in the activity without judgment.” The possible uses of mindfulness as a mental health cure are almost endless. Mindfulness-based therapy can be used in a variety of ways and to treat a spectrum of disorders, which likely contributes to its popularity as a therapeutic tool. “Mindfulness-based therapy, for instance, can be used with intellectual disorders, autism spectrum, trauma, eating disorders, anxiety, depression, bipolar disorder and sexual dysfunction disorders,” says Alexandra Mejia, an LMHC based in New York. Although some counselors think that almost any disorder can be at least partially treated with mindfulness-based counseling, Drew Mikita, a licensed professional counselor (LPC) with a private practice in Colorado, says that certain disorders such as psychotic disorders may be harder than others to treat with this approach. “There’s so much going on [with psychotic disorders] from a biochemical standpoint,” he notes. “It’s going to be very challenging to get somebody who’s in an active hallucination to [ground themselves], but that’s probably who needs it the most.” Mikita also thinks that neurocognitive disorders, such as dementia, would be difficult to treat via mindfulness because the client may have difficulty accessing the skills they need such as taking in their surroundings. But it wouldn’t be impossible, he adds. Mindfulness-based counseling can take many different forms, including breathing exercises, meditation and grounding techniques, and they are often used in conjunction with other types of therapies. James Killian, an LPC at Arcadian Counseling in Connecticut, integrates mindfulness-based treatment into his practice by using acceptance and commitment therapy, which involves a client becoming aware of their feelings, accepting those feelings and then letting them go. “It’s learning how to be present in the moment, open[ing] up to what’s happening and doing what matters from a values-based perspective,” he says. This clinical approach is heavily steeped in mindfulness, which is something he really likes about it. Jennifer Carey, an LMHC who works at a private practice in Massachusetts, incorporates mindfulness into internal family systems, a form of therapy that believes we all have different parts or subpersonalities (e.g., perfectionist, people pleaser, sadness, anxiety) within us. “The parts are fine if they’re in balance,” she explains. “But when they go to an extreme and hijack our system and take away our calm, our confidence, our centeredness and our clarity that’s when there’s a problem.” Mindfulness practices, such as meditation and breathing exercises, help clients explore and get to know these different parts of themselves, and it allows them to examine all the different aspects of their life from a place of neutrality, she says. “If you can come from this place of calm and quiet, you can approach it differently,” she adds, as opposed to having the emotions, like anxiety, controlling you.

Mindfulness vs. meditation

People often conflate the terms “mindfulness” and “meditation” and don’t understand how they differ. Yuan says that when people think of mindfulness, they often picture meditation instead — someone sitting for a period of time and engaging in self-talk, guided meditation from apps and breathwork. “I think of mindfulness as a state of mind and a state of being, whereas meditation is more of a practice or a technique to help you achieve mindfulness,” she says. A lot of people might find the idea of meditation impossible, either because of their religious beliefs or because they feel as though they cannot sit still in silence for long periods of time. “I had somebody tell me they weren’t ready for meditation because their anxiety was so crippling [that] sitting … and being alone with their thoughts was too overwhelming,” says Mikita, an associate professor of psychology at Colorado Mountain College. So he suggested the client try yoga as an alternative to meditation because it is more active and could still serve as a distraction for the client’s anxiety. “I think of meditation almost as an advanced mindfulness practice,” Mikita continues. Yoga is “kind of [like] dipping your toe into that mindfulness, that thought awareness and presence.” Carey uses meditation as one of her main therapeutic tools. Meditation is “connecting with your breath, connecting with the present moment, to meet your racing thoughts or uncomfortable emotions of physical sensations with neutral nonjudgment,” she says. It’s “taking a pause and being able to separate yourselves from some of those thoughts. … And other times, it’s more like a guided imagery.”

A variety of mindfulness tools

Meditation is one type of mindfulness practice, but sometimes it’s just not the right mindfulness tool for a particular individual. In that case, there are a lot of other tools that clients can use instead. Mikita says mediation doesn’t work well for him personally, so he prefers to use other mindful practices. For example, he may sit outside and enjoy the natural beauty that surrounds him. He also doesn’t assume that one type of mindfulness practice will be the best approach for his clients. Instead, he says he works with clients to find the mindfulness practice that is right for them. They sometimes try a few different practices in session, and he will remind them that many mindfulness exercises may feel forced at first but not to give up. He will also show them studies and research as to why meditation or other mindfulness practices may work for them. Mikita’s favorite mindfulness exercise is the 5-4-3-2-1 technique. During this exercise, the client looks around at their surroundings and engages their five senses (e.g., five things they see, four things they feel, three things they hear, two things they smell and one thing they taste) to help bring them back into the present moment. “It also allows you to be distracted from some of the maybe static or white noise that we often get in our inner monologues of being depressed” or worrying about what will happen next, he says. “It allows us a little bit of breathing room by finding that moment of being present.” Killian helps clients find the best mindfulness tool by asking them what comes to mind when he brings up mindfulness. This helps him gain a better understanding of how clients view mindfulness. “I’ve heard everything from a state of heightened enlightenment or meditation [to] misconceptions,” he says. After learning more about their understanding of mindfulness, Killian teaches his clients how and why it can be beneficial and helps them learn techniques that work for them. He finds that the body scan technique is often helpful for clients who don’t have a lot of time to practice mindfulness. With this technique, a client pays attention to their physical self and notices the different sensations they feel in their body as well their reactions to those sensations as they “scan” their body from head to toe. Killian also asks clients to take mental notes of their thoughts and feelings they have during the exercise. This exercise is a versatile tool because the body scan can last as long or as short as the client needs, he says. Mejia tells her clients that almost any activity — even brushing their teeth, showering or examining a piece of fruit — can be turned into an opportunity to practice mindfulness as long as they focus on the feelings, thoughts and sensations that are happening in that moment. Mindfulness practices can also be incorporated at any point during a counseling session, Mejia adds. Counselors can begin a session with mindfulness exercises to help prepare them for the session. They can also break up a session with a mindfulness exercise if the client is starting to be overwhelmed, or they can end using this approach to help a client relax after a tumultuous session, she says.

Trauma-informed mindfulness

When mindfulness exercises are led by somebody who is inexperienced, however, issues can occur. During a conference Carey attended, an inspirational speaker (who was not a licensed mental health professional) led the audience in a mindfulness exercise, and the experience ended with one of the participants having a severe emotional reaction. This happened, Carey says, because the speaker was unable to properly reground the group after the meditation session. There were ways that this could have been prevented, Carey notes. Before the experience, the speaker could have informed the participants about the purpose of the exercise and the brain science behind it. During the session, the speaker could have had the participants ground themselves and informed them that if they felt their minds begin to wander, they could just bring their attention back to their breath. Afterward, it would have been a good idea to guide “participants in a nonjudgmental and compassionate way to have a moment to process what came up for them,” Carey adds. The speaker could also have had a licensed mental health professional help them conduct this mindful exercise. Even when mindfulness exercises are led by an experienced professional, there are drawbacks to using meditation as a mindfulness tool. David Forbes, an LMHC and an associate professor of school counseling at Brooklyn College of the City University of New York, says that sometimes, especially if a client has experience severe trauma, mindfulness practices can be triggering to the point that the client needs to stop. Forbes also notes that Willoughby Britton, a clinical psychologist and leading researcher in mindfulness-based interventions, has found that mindfulness practices can produce difficult triggering events for anyone, not just those with a trauma or psychological history, and at any time, not just when engaging in an intensive mindfulness retreat. A study published in Clinical Psychological Science in 2021 found that 58% of the 96 participants reported at least one adverse meditation-related effect, such as hypersensitivity, nightmares, anxiety, dissociation or flashbacks. In addition, 37% reported that their symptoms interfered with their daily life, and 6% had side effects that lasted at least a month. Mindfulness requires people to pay attention to their internal experiences, Forbes says, so if someone is focusing on unpleasant events or feelings, it can trigger emotions such as anxiety, panic and fear. Therefore, he stresses the importance of counselors being trauma informed when using mindfulness interventions, so they can help clients deal with these feelings if they come up. “Not all of mindfulness is pleasant. There are some meditations that can be difficult to do because of the content,” Mejia says. “There are also meditations that have [clients] sit with emotions or sit with difficult experiences or thoughts on their mind that can be unpleasant.” But sitting with these difficult or unpleasant emotions is necessary, she explains, because that will help the emotion become more manageable or less intense. This process should be gradual. Clients shouldn’t start by meditating and reflecting on difficult trauma, Mejia says. Instead, they need to gradually build up from focusing on daily frustration before moving into deeper trauma with their mindfulness practices. She prepares her clients to move from small mindfulness exercises to more difficult ones to help them eventually uncover and process their “greatest trauma” or “most difficult relationship.” People who are triggered by meditation or mindfulness are different from those who refuse to use mindfulness or are critical of the practice, Forbes adds. For those who are hesitant but otherwise suited for mindfulness, it’s the counselor’s job to get their clients “over that hump.” But having a caring supporting therapist is more important than mindfulness, he says.

No quick fixes

Although mindfulness has many benefits, such as helping reduce stress, it has some downsides as well. The time spent on mindfulness during Hoge and colleagues’ study (45 minutes a day plus a 2.5-hour class per week) is more than most people can devote. But that does not mean one should completely skip mindfulness if they don’t have 45 minutes a day to spare. Carey says that any amount of time geared toward mindfulness is a net positive. She often recommends clients set an alarm on their phone to chime throughout the day to remind them to stop and engage in some form of mindfulness practice, such as doing breathing exercises for a few seconds. Even just noticing the way it feels to walk from one place to another can be a mindful act, she adds. Taking short breaks to practice mindfulness in this way can help to break up racing thoughts and make mindfulness “accessible to even the busiest person on the planet,” Carey says. But mindfulness can’t always work on its own and it is not a substitute for therapy, Forbes stresses. “My position is that the traditional approaches of mindfulness in counseling, either with individual or groups, are necessary but not sufficient. Both in their work with clients and in their own personal and professional development, counselors need to go beyond the individualistic, intrapsychic and adjustment practices that characterize much of counseling — and mindfulness — and take a more integral approach,” he says. “Both counseling and mindfulness can help people make aspects of themselves objects of their own awareness, so let’s expand that awareness to include as many perspectives as possible.” The counselors interviewed for this article all agree that mindfulness has become mass marketed as a “quick fix” for problems. Viewing mindfulness as a commodity can also shift the blame of failure onto individual workers, Yuan says, which overlooks systemic issues of companies having unrealistic and unhealthy expectations of their workers. “We live in a very individualistic, competitive society where people are conditioned to blame themselves for their failure, where they blame themselves for almost anything,” Forbes says. With “any problem you end up solely looking within without looking at the sources.” That isn’t to say that mindfulness is a negative thing, but people can’t expect it to get rid of the underlying problem. Using mindfulness to calm one’s anxiety can be helpful, he notes, but it doesn’t solve the source of anxiety (such as an unhealthy work environment or financial stress). This tendency to view mindfulness practices as a quick fix plays out in other areas outside of counseling as well, Mikita adds. For example, she says it’s common in yoga classes for people to skip out on the “shavasana,” or corpse pose, which is an important aspect of yoga that helps ground people at the end of the class. Mindfulness is also something people need to continually practice throughout their lives. At no point will a person “outgrow” the need for mindfulness, Killian notes. In fact, he often reminds his clients that mindfulness is not something to achieve. “Mindfulness isn’t something you’re going to practice for a couple of weeks and then you’re done,” he says. “It’s an ongoing thing. It’s kind of a new way of thinking. There isn’t ever going to be a time when you don’t have to do it anymore. It’s always going to be something you’re working on and progressing, and it’s always going to be evolving for each individual in their own unique way.”

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Samantha Cooper is a staff writer for Counseling Today. Contact her at scooper@counseling.org.

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