Detached Mindfulness Techniques

The concept of detached mindfulness (DM) was briefly introduced in Chapter 1. In this chapter I examine the concept in greater detail and describe 10 techniques that can be used to train individuals in the rapid and flexible deployment of this metacognitive strategy.

DM was originally described by Wells and Matthews (1994). It concerns the manner in which an individual relates to his or her cognition and the development of flexible control of attention and thinking styles. The ATT reviewed in the previous chapter offers a specific strategy designed to impact on and improve flexible control of attention and to strengthen the ability to disengage from unhelpful ways of relating to inner experiences. DM techniques are focused more on developing meta-awareness in the context of suspending conceptual processing and separating self from cognitive events.

I have previously described DM as

a state of awareness of internal events, without responding to them with sustained evaluation, attempts to control or suppress them, or respond to them behaviorally. It is exemplified by strategies such as deciding not to worry in response to an intrusive thought, but instead allowing the thought to occupy its own mental space without further action or interpretation in the knowledge that it is merely an event in the mind. (Wells, 2005b, p. 340)

As the name implies, DM has two features: (1) mindfulness and (2) detachment. DM consists of both features simultaneously. Let’s address each of these components in turn, beginning with mindfulness.

We use the term “mindfulness” in DM to refer specifically to being aware of inner cognitive events, namely, thoughts, beliefs, memories, and feelings of knowing. Effectively, the use of the term “mindfulness” is intended to refer to metacognitive awareness of thoughts and beliefs where attention can be flexibly focused on such inner experiences without being locked onto any one of them.

We use the term “detachment” to refer to two further factors. The first and most important dimension of detachment denotes detachment of any reactive engagement with the inner event. That is, the person refrains from further appraisal of or attempts to cope in response to the inner event. The concept of DM contains the antithesis of the CAS. It is about stopping any conceptual or behavioral involvement with inner experiences. It consists of abandoning worry, rumination, suppression, control, threat monitoring, avoidance, or attempts to minimize (nonexistent) threat in response to cognition.

The second component of detachment involves the person experiencing an inner event as an occurrence that is independent of general consciousness of the self (i.e., the individual has a perspective in relation to the event in which consciousness is located separately from it). It is as if the person is aware of the perspective of the self as an observer of the thought or belief. This feature is harder to grasp. Therefore, an example may help to illustrate the construct. This example is based on a male patient with OCD.

THERAPIST : It sounds as if you often have thoughts about contamination.

PATIENT : Yes, every time I see a stain I think, “It must be contaminated” or “I’m contaminated.”

THERAPIST : So how aware are you of repeatedly thinking “It must be contaminated”?

PATIENT : I’m always thinking it when I see stains.

THERAPIST : Of course. But how often do you stop and consciously reflect on the fact that you have had that thought again?

PATIENT : I don’t, I just act to prevent harm.

THERAPIST : So the first thing you can do is simply to stop and be consciously aware of having the thought. That is called mindfulness.

PATIENT : Yes, but what if it’s true?

THERAPIST : Irrespective of whether it is true or not, it is still a thought.

PATIENT : Yes, but I can’t ignore it.

THERAPIST : Ignoring the thought isn’t the idea. I want you to become aware of it as a thought in your mind that you can observe. I want you to become mindful of it.

PATIENT : How would I know it is just a thought?

THERAPIST : What else could it be?

PATIENT : Well, it could be true.

THERAPIST : Whether it is true or not, it will always be a thought. Whether it is true or not, I would like you to practice detachment from it and see it as a thought separate from yourself.

PATIENT : I’m not sure what you mean.

THERAPIST : Can you have the thought “I’m contaminated” right now?

PATIENT : Yes.

THERAPIST : Look at that stain on the floor. Can you close your eyes right now and have the thought “I’m contaminated”?

PATIENT : Okay.

THERAPIST : Now pay attention to that thought. Don’t do anything to change it. Take a step back in your mind and look at the thought and as you do so concentrate on where you are as the observer watching that thought in your head. Concentrate on what it feels like to be detached from that thought. Can you observe that as a thought separate from the sense of yourself?

PATIENT : Yes, I can.

THERAPIST : Can you detach yourself from your thoughts like that in future?

PATIENT : Yes, but I will still need to wash.

THERAPIST : Part of detachment from the thought involves watching it as an observer and postponing doing anything else in response to it. How long could you postpone washing?

PATIENT : I’m not sure.

THERAPIST : What about postponing it for an hour to start with?

In this example the therapist introduces the concept of mindfulness in terms of the patient increasing his subjective awareness of the occurrence of thoughts about contamination. This awareness begins to build the scaffolding to support the shift from the object mode in which thoughts are fused with facts to the metacognitive mode in which thoughts are events in the mind. In this process the therapist encourages the patient to refrain from evaluating whether or not the thought is a fact by emphasizing that it remains a thought irrespective of its validity. The patient’s main task is to be aware of the thought as a mental event and to experience it as such. The dialogue continues with the introduction of detachment in the form of separating the self from the thought and disengaging coping responses (i.e., postponing washing).

AIMS OF DM

There are several aims in using DM. It can be used to shift patients away from the object mode of experiencing and into the metacognitive mode. It can be used as a means of interrupting perseverative processing in the form of worry and rumination. It can be used to increase executive control over the allocation of attention. It also enables patients to escape the influence of thoughts on self-concept.

The effect of DM is determined by how it is used and the rationale for using it. It is imperative that DM is not used as an emotional or cognitive avoidance technique or as a means of preventing erroneous feared outcomes. For example, a patient may inappropriately use DM as a means of controlling or counteracting the effects of “dangerous thoughts,” a misuse that could maintain the mistaken belief that thoughts can cause harm. More specifically, the aim is not to teach DM so that it can become another form of maladaptive thought control strategies. It is not a means of avoiding thoughts. Instead, it is about relating to thoughts and experiencing them in a new way that necessitates overt and covert inaction. It is a “do-nothing” strategy, the antithesis of coping and the CAS. That is why it is a state of “detached awareness.” It is also detached awareness because the process of experiencing DM involves disconnection of the sense of self from the contents of consciousness as a more profound and deeper experience. This latter sense can be particularly useful when the thought or “feeling” that intrudes into consciousness is fused with the self-concept.

ELEMENTS OF DM

 

I have described how DM is a type of inner awareness that occurs in the absence of effortful conceptually based self-processing. Specifically, it is an awareness of thoughts in which they are experienced as passing events in the mind that are distinct from reality and separate from the self. Since DM is awareness in the absence of conceptual processing, it requires metacognitive control of analytical and perseverative forms of thinking. DM is simply awareness without judgment of the position of the self in relation to a mental event. The psychological elements of DM can be isolated and conceptualized as involving the following:

 

1.      Meta-awareness (i.e., consciousness of thoughts).

2.      Cognitive decentering (i.e., comprehension of thoughts as events separate from facts).

3.      Attentional detachment and control (i.e., attention remains flexible and not anchored to any one thing).

4.      Low conceptual processing (i.e., low levels of meaning-based analysis or inner dialogue).

5.      Low goal-directed coping (i.e., behaviors and goals to avoid or remove erroneous threat are not implemented).

6.      Altered self-awareness (i.e., experience of a singularity in consciousness of self as an observer separate from thoughts and beliefs).

AN INFORMATION-PROCESSING MODEL OF DM

 

Progress in the development of useful experiential techniques is most likely to be made by reference to an information-processing analysis of the goals and effects of such techniques. DM is based on such an approach. In earlier work I have described an information-processing model of DM requirements and effects (Wells, 2005b). I briefly summarize that model here (see Figure 5.1).

DM is intended to impact on the CAS and the metacognitive processes and knowledge that drive it. DM can be conceptualized as acting on the interrelated cognitive and metacognitive subsystems. The metacognitive subsystem consists of information about cognition stored as a library of knowledge or beliefs that can be accessed to interpret and control thinking. It also consists of a model of the activities of online processing, which it monitors and controls in pursuit of the goals of processing. The relationship between the metacognitive and the cognitive subsystems can be represented as a flow of information involving monitoring and control, as posited by Nelson and Narens (1990).

The model of the cognitive subsystem held by the metacognitive subsystem is built from the monitoring of events in ordinary cognition (i.e., online processing) and projection of their status into the future in relation to a reference standard. It consists of a current representation of the status of ordinary cognition in relation to a set of goals. The model not only requires real-time feedback from the online level but the accessing of knowledge from long-term memory.

This specification of the components of and the relations between the subsystems leads to hypotheses about the information-processing parameters that have to be met to achieve DM. In this model DM requires the following conditions to be present:

 

1.      Activation of appropriate knowledge (plans) for controlling thinking.

2.      A mental model of the mindfulness state.

3.      Ongoing monitoring and control of that state.

4.      Sufficient attentional resources and flexibility for executive control to allow accessing and implementation of DM.

5.      Development of a model of self that is separate from individual negative cognitions (beliefs and thoughts).

FIGURE 5.1. Metacognitive model of DM grounded in the S-REF framework. From Wells (2005b). Copyright 2006 by Springer Science and Business Media. Reprinted by permission.

This analysis of the features of DM and its requirements sets the stage for developing specific DM techniques that are grounded in theory. It also means that the effects of different treatment techniques may be formulated in terms of this a priori model. For example, the act of identifying automatic thoughts by using a dysfunctional thoughts record might increase metacognitive monitoring and allow decentering, thereby strengthening metacognitive awareness skills. However, this action might not satisfy the other psychological elements of DM, such as attentional detachment, low conceptual processing, and low goal-directed coping. The process of interrogating thoughts by directing the patient to rationally question them supports the activation of knowledge (plans) that in turn supports a high level of conceptual processing of these thoughts, which is incompatible with DM.

The model (Figure 5.1) and the conditions specified for DM suggest that individuals must be able to activate plans for controlling thinking to accomplish the desired state. In some instances these plans may be disrupted or not highly developed, meaning that initial training to strengthen control plans may be required (e.g., attention training). Most individuals have an intellectual concept of mindfulness but lack the model at the metacognitive level to guide them in experiencing this state. Patients’ acquisition of the model can be achieved by encouraging them to experience focal awareness of their cognitive events (e.g., by counting thoughts, engaging in a free-association task—see below). Detachment is facilitated by experiential exercises in which individuals practice (1) suspension of active conceptual processing and control and (2) experiential awareness of self as separate from thoughts. These factors are built into the techniques described later in this chapter.

DM AND OTHER FORMS OF MINDFULNESS

 

The term “mindfulness” has been used in many different ways in the psychological literature. It has been linked to a state of effortful and conscious controlled processing (Shiffrin & Schneider, 1977), a state that is opposite to “mindlessness.” Mindlessness is equated with habitual or automatic processing. This characterization is simply another way of differentiating controlled versus automatic processing. It does not implicate metacognition and conscious awareness of thoughts themselves as does DM.

The heterogenous nature of mindfulness within the psychological and treatment literature is evident in the self-report scales developed to assess this construct. For example, Brown and Ryan (2003) developed the Mindful Attention Awareness Scale (MAAS) to assess the qualities of consciousness associated with well-being. Many of the items appear to assess the tendency not to notice information and to behave as if one is on automatic pilot (e.g., “I could be experiencing some emotions and not be conscious of it until some time later”; “I tend to walk quickly to get where I’m going without paying attention to what I experience along the way”). These items are similar to other psychological concepts such as cognitive failures as measured by the Cognitive Failures Questionnaire (Broadbent, Cooper, Fitzgerald, & Parkes, 1982), a measure of everyday cognitive and performance errors. In these approaches mindfulness is linked either to levels or the efficiency of attentional functioning, but there is limited separation between it and related constructs.

Mindfulness is also fused with concepts such as acceptance (e.g., Hayes, Strosahl, & Wilson, 1999), which means taking thoughts as thoughts and feelings as feelings without the need to avoid them. This is conceptually similar to DM but does not focus specifically on the suspension of worry and rumination and on developing a sense of self as separate from beliefs although it may separate self from thoughts and feelings.

Drawing on previous approaches, Bishop et al. (2004) offer an operational definition of mindfulness that has two components: (1) control of attention so that it is maintained on immediate experience, thereby allowing for increased recognition of mental events in the present; and (2) adopting an orientation of curiosity, openness, and acceptance to one’s present experiences. The first component is a feature of DM, and implies greater metacognitive awareness. However, this definition does not include separation of the sense of self from inner events as does DM. The second component takes us further away from DM and introduces the concepts of curiosity and acceptance. It is not clear how such states are implemented, but they are likely to involve active engagement with thoughts, which is not a feature of DM.

Mindfulness has gained prominence as a term equated with Buddhist meditation (e.g., Kabat-Zinn, 1994). DM does have some similarity to the concepts of mindfulness derived from meditation practices, but it is also different from these approaches.

From the meditation perspective, mindfulness has been described as “paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally” (Kabat-Zinn, 1994, p. 4). This is a very broad description that partially covers DM and would also capture some features of attention training (Wells, 1990), but omits some of the unique features of DM.

In the work of Kabat-Zinn (1990, 1994) mindfulness is equated with paying attention. Paying attention to the breath is used as a means of focusing on moment-to-moment experience. Such attention offers a means of directly experiencing the moment without thinking about it. This includes being aware of the thought stream without judging it, cultivating trust in the self, and “letting go,” or accepting things as they are. This kind of mindfulness is much more general than the concept of mindfulness in DM, and despite containing reference to awareness without thinking, it is imprecise and somewhat contradictory. In particular, it requires daily practice and focusing on breathing to anchor attention, which suggests some kind of body-focused processing. Furthermore, it is difficult to reconcile cultivating trust in the self and acceptance with the absence of some form of value judgment. The features of mindfulness as practiced in meditation appear to conflict with one another and stand apart from the features of DM that eschew judgment and body focusing.

The conceptual and practical differences between mindfulness in DM and mindfulness used in these other contexts can be summarized as follows:

 

·         DM does not involve meditation.

·         DM does not require extensive and continuous practice.

·         DM does not require broader features of mindfulness such as increasing present-moment awareness.

·         Mindfulness in meditation tends to use body-focus exercises such as focusing on the breath to bring attention back to the present if it is captured by thoughts. DM does not have body-focused anchors for attention.

·         DM specifically concerns developing meta-awareness of thoughts rather than present-moment awareness.

·         Mindfulness has many meanings with a limited consensus. The definition and features of DM are more tightly specified in advance.

·         DM separates meta-awareness from detachment.

·         DM is specific about the suspension of conceptual processing.

·         DM is specific concerning the suspension of goal-directed coping.

·         DM is specific in the concept of separation of sense of self from mental phenomena.

It is likely that the effectiveness of techniques will depend on developing strategies grounded firmly in information-processing models that specify the more or less adaptive means of achieving mindfulness. The principle objective of meditation-derived mindfulness differs from that of DM, whose purpose is to modify well-specified metacognitive structures and processes that cause psychological disorder. The future development of these techniques might be well served by grounding them in a model of their requirements and consequences, as might be offered by the metacognitive approach.

TEN TECHNIQUES

 

This section presents 10 basic techniques that are used in MCT to promote a state of DM or components of it. This section is based on an earlier paper (Wells, 2005b) describing some of these strategies.

Metacognitive Guidance

 

“Metacognitive guidance” refers to the use of structured questioning to promote meta-cognitive self-reflection during exposure to problematic situations or stimuli. Useful questions include:

“Can you look through your thoughts at the outside world?”

“Can you see your thought and what is going on around you in the situation at the same time?”

“Are you living by your thoughts or by what your eyes reveal?”

In one case of a patient with washing compulsions the therapist invited the patient to enter a situation that activated his distress and urge to wash, specifically, walking along the street close to a trash can. First, the patient did this without any therapist guidance and was simply told to find a distance from the can that raised some anxiety that was tolerable. Next the therapist asked him to move a little closer to the can and provided metacognitive guidance as follows:

THERAPIST : How distressed are you feeling right now on a scale of 0-100?

PATIENT : Not too bad. I would say 30.

THERAPIST : In a moment I want you to take one step forward and move closer to the trash can. But as you do that I want you to become aware of your inner thoughts. What are you saying to yourself as you step closer? Try that now.

PATIENT : I really don’t want to do this.

THERAPIST : What thought did you have that made you feel that way?

PATIENT : I thought it’s probably contaminated with bodily fluids.

THERAPIST : Was that a verbal thought or an inner picture?

PATIENT : It was a verbal thought: “What if it has bodily fluids on it?”

THERAPIST : Good. I want you to take that step closer and watch or listen to that verbal thought. See or hear those words in your mind and look through them at the trash can to discover the truth about your thought.

PATIENT : (Takes a step forward.)

THERAPIST : Well done. Could you experience seeing through your thought when you did that?

PATIENT : Yes, sort of.

THERAPIST : Does that tell you anything about your thought?

PATIENT : Well, it’s just a thought. Taking that extra step hasn’t really changed anything.

THERAPIST : Good. You can learn to relate to your thoughts in a new way without avoiding situations. What about taking another step? This time look through your thought and ask yourself: “Do my eyes reveal to me that I have been contaminated?”

PATIENT : (Takes a further step.)

THERAPIST : What do your eyes tell you?

PATIENT : Well, I can’t see that I’ve been contaminated.

THERAPIST : So is it better to live by your thoughts or by what your eyes reveal to you?

PATIENT : Maybe I shouldn’t be thinking is it or isn’t it contaminated then?

THERAPIST : Could you practice looking through your thoughts instead of washing each time you have a thought?

PATIENT : But when should I wash?

THERAPIST : Only before touching food, after eating, or after visiting the toilet, but certainly not after having the thought.

PATIENT : So you’re saying this is just a thought and I don’t need to wash?

THERAPIST : That’s it. Have you been giving this thought too much importance?

PATIENT : I’ve been accepting it as true.

THERAPIST : Can you practice relating to this thought in a new way from now on?

Free-Association Task

 

In this task the therapist asks the patient to sit quietly and watch the “ebb and flow” of thoughts or memories that are triggered spontaneously by verbal stimuli. The aim is not to actively think about items or memories but to watch the spontaneous events or lack of such events in consciousness. The task is introduced in the following way:

“So that you can become familiar with using detached mindfulness, it is helpful to practice in response to spontaneous events in your mind. By doing this you can learn to relate to these events in a new way. In a moment I will say a series of words to you. I would like you to allow your mind to roam freely in response to each word. Do not control or analyze what you think, merely watch how your mind responds. You may find that nothing much happens, but you may find that pictures come into your mind. It doesn’t really matter what happens. Your task is to passively watch what happens without trying to influence anything. Try this with your eyes closed. I’m going to say some words now: apple, birthday, seaside, tree, bicycle, summertime, roses.

“What did you notice when you watched your mind?

“The idea is that you should apply this strategy to your negative thoughts and feelings. Just watch what your mind does without getting caught up in any thinking process.”

 

Tiger Task

 

This is a task that our patients particularly enjoy. In this task participants are asked to passively observe nonvolitional aspects of imagery as a means of experiencing DM. The following instructions are used to implement the procedure:

“So that you can feel what detached mindfulness is like and what you need to do to experience it, I want to introduce you to an exercise. We call this the “tiger task.” In a moment I’m going to ask you to close your eyes and form an image of a tiger. Let’s do that now: close your eyes and conjure up an image of a tiger. Do not attempt to influence or change the image in any way. Just watch the image and the tiger’s behavior. The tiger may move, but don’t make it move. It may blink, but don’t make it blink. The tiger may wag its tail, but don’t make it do that. Watch how the tiger has its own behavior. Do nothing, but simply watch the image, see how the tiger is simply a thought in your mind, that it is separate from you and it has a behavior all of its own.”

 

Following practice, the therapist then asks the patient about the movements the tiger made and how the image changed: “Did you make the tiger move or did it happen spontaneously?” When the patient experiences the movements as spontaneous, this is brought to the patient’s attention as an experience of DM. The therapist then asks if this process can be applied to spontaneously occurring thoughts of a negative kind.

Suppression–Countersuppression Experiment

 

When patients are highly invested in controlling and avoiding particular thoughts, and when they erroneously equate the concept of DM with having a blank mind, the suppression–countersuppression experiment is particularly useful. In these cases it is important that the therapist distinguishes between suppression and DM so that patient misunderstanding and misuse of DM is minimized. This technique consists of a brief period of attempting to suppress a target thought contrasted with a subsequent period of thought awareness. An example of this technique is given below:

“It is important that you learn the difference between detached mindfulness and trying to control or avoid thoughts. Trying to stop thoughts is a form of active engagement with them since you are trying to push them out of your mind. Pushing something is hardly leaving something alone and so this effort backfires and you remain in contact with your thoughts.

“How can you push against a door and not be in contact with it by some means? Let’s see this effect in action. For the next 3 minutes I don’t want you to think about a blue giraffe. Don’t allow yourself to have any thought connected with it, try to push it away. Off you go.

“What did you notice? Did you think of a blue giraffe?

“Let’s now try detached mindfulness and see what happens. For the next 3 minutes let your mind roam freely and if you have thoughts of blue giraffes I want you to watch them in a passive way as part of an overall landscape of thoughts. Try that now.

“What did you notice? How important was the thought of the blue giraffe the second time around?”

 

The therapist should then discuss how suppression gives thoughts extra salience and importance, and how DM can be used to allow thoughts to roam freely as passing events in the mind that do not require an active response. The procedure may then be repeated asking the patient to become aware of being the separate observer of the thought.

Clouds Metaphor

 

In some versions of this task participants were asked to use imagery to respond to thoughts: thoughts were to be imagined as printed on clouds and allowed to drift across the sky. However, in this form the task involves responding to thoughts and then transforming them. As such it is not a true version of DM. Another version is now preferred in which clouds are simply used as a metaphor to convey the experience of DM. The therapist offers the following account:

“One way to understand detached mindfulness and what it requires is to consider experiencing your thoughts as you would experience clouds passing you by in the sky. The clouds are part of the Earth’s self-regulating weather system, and it would be impossible and unnecessary to try and control them. Try to treat your thoughts and feelings like you would treat passing clouds and allow them to occupy their own space and time in the knowledge that they will eventually pass you by.”

 

Recalcitrant Child Metaphor

 

This metaphor helps the patient to understand the different effects of active engagement with thoughts versus detached awareness (mindfulness). The therapist gives the following instruction:

“You can think of detached mindfulness as similar to the way you might deal with a child. How would you manage a child misbehaving in a store? You could pay a great deal of attention to the child and try to control the child’s behavior. But if the child craves attention this response could make things worse. It is better not to actively engage with the child but to keep a passive watch over the child without doing anything.

“Your negative thoughts and beliefs are like that child. If you pay them a great deal of attention, if you control them or use punishment, they misbehave even more. It is better not to try and control or actively engage with them, just keep a watching manner over everything. As you do this, try to be aware of yourself as the observer of these things.”

 

Passenger Train Metaphor

 

This is an alternative to the clouds metaphor described above. Here the patient is asked to deal with intrusive thoughts and feelings in the same way that he or she would deal with an express train passing through a station:

“It is helpful to think of yourself as a passenger waiting for a train. Your mind is like a busy station and your thoughts and feelings are the trains passing through. There is no point in trying to stop and climb aboard a train that is passing by. Just be a bystander and watch your thoughts pass through. There is no point in climbing aboard to be whisked away to the wrong place.”

 

Verbal Loop

 

The repeated presentation of thoughts either by a recording device or through repeated vocalization has the effect of decreasing their attentional salience and diminishing their meaning because they are experienced more as sounds than as inner conveyors of information. This technique is presented with a metacognitive rationale as follows:

“I would like you to listen to a recording of your intrusive thoughts [or repeat quietly to yourself your thought …]. As you do so you should relate to them in a special way. Treat the thoughts as a set of sounds and do not engage with them in any other way. They are merely sounds in the outside world. Keep in mind as you listen that you are simply a listener safe in the knowledge that thoughts are not facts, they are simply events in your mind.”

 

Detachment: The Observing Self

 

We have seen that detachment includes both disengagement of control and conceptual processes and experiencing thoughts or beliefs as an observer with no further divisible sense of consciousness. It is a core, indivisible, felt sense that has no propositional reference and no further point of regression. It is a singular sense of self. In this state the individual is observer of the thought and separate from any thought itself.

This level and experience of DM is accomplished by asking patients questions that direct their attention in a particular way during their monitoring of thoughts. These questions are usually incorporated in the above experiential techniques to intensify the experience of DM once awareness and discontinuation of conceptual processing has been achieved. Specifically the patient is asked during these exercises:

“Are you the thought or the person observing the thought? Try to be aware of your location and what it is like to be the observer. You exist entirely separately from thoughts.”

 

Or:

“Are you the belief or the person observing the belief? Try to be aware of how your consciousness as the observer is separate from your beliefs.”

 

Daydreaming Technique

 

It is typically the case that our daydreams are experienced in object mode. We become completely immersed in them and live them as momentary reality. The practice of shifting to detached observer during daydreaming can provide a powerful subjective experience of DM.

The therapist asks the patient to engage in a pleasant daydream, such as driving an exotic car or sipping champagne on a Caribbean beach. Then the therapist asks the patient to allow the daydream to continue but to step back and be aware of the self in the present as observer of the daydream as it unfolds.

REINFORCING DM USING SOCRATIC DIALOGUE

 

On completion of experiential exercises, the therapist reinforces DM during the course of treatment by asking questions when a negative thought or belief is activated. These questions include the following:

 

“Are you the belief or the person that observes and uses that belief?”

“Is that thought important or is it a passing event in your mind?”

“Can you see yourself as separate from that idea?”

“What are the advantages of practicing being separate from that thought?”

“In future, can you separate your sense of self from the mere occurrence of that thought?”

HOMEWORK

 

The application of DM is a task set for homework. The patient is instructed to notice the triggers for worry/rumination and unhelpful coping behaviors such as avoidance/suppression (the CAS) and to apply DM to the trigger. Typically, DM is combined with other techniques such as the worry/rumination postponement technique (see Chapter 6), which facilitates detachment of continued processing from initial intrusions.

The therapist reviews the range of thoughts to which DM is applied in the first few sessions, with a view to increasing this application and enhancing the patient’s awareness of triggers for the CAS. The therapist makes careful note that DM is not being inappropriately applied as a coping strategy aimed at preventing erroneous threats.

In order to determine an effective frequency of the technique, the therapist asks about the proportion of triggers to which DM has been applied. As a rough rule of thumb, the therapist aims to achieve a 75% application rate during treatment. The effective use of DM can also be gauged by examining scores on the CAS-1 rating scale. In particular, items 1 and 3 (worry and coping) are indicative of the level of maladaptive engagement with internal triggers (i.e., the antithesis of DM).

APPLICATION OF DM IN MCT

 

MCT is not a treatment based on individual techniques. It is quite possible to effectively implement MCT without specifically training patients in DM. It is important that the therapist does not see this technique or any other technique as the mainstay of treatment. However, DM is a component of MCT that can act as a catalyst for meta-level change.

Application of DM early in therapy is recommended in conjunction with postponement of worry and rumination (see Chapter 6). Usually the technique is introduced in the first or second session but is not intensively practiced thereafter. In the treatment of depression we prefer the regular practice of the ATT at each session as a more structured and intensive means of achieving executive control and with the aim of accomplishing important features of DM.

Throughout its usage the therapist normally tracks the patient’s goals in using the technique and monitors examples to ensure that it is used appropriately. The therapist should be aware of misuse of DM as a distraction technique, a means of avoiding anticipated threat, and as a means of anxiety control.

A 26-year-old woman undergoing MCT for depression described how she had inconsistent results applying DM, stating that “I’m not always successful in making my thoughts go away.” A very useful discussion followed in which the therapist discovered that she had been inappropriately trying to stop negative automatic thoughts (e.g., “I’m worthless”) rather than applying DM to them and interrupting further conceptual analysis of her failings and weaknesses.

 

Later in treatment it may be necessary to ban the use of DM as a prelude to or in conjunction with experiments designed to challenge negative beliefs about loss of control and the danger of thoughts and symptoms. The continued use of DM can prevent some patients from discovering that they cannot lose mental control since they attribute the nonoccurrence of the catastrophe to use of the technique.

CONCLUSION

 

DM is  state of relating to inner thoughts and beliefs in a particular way. It is intended to increase flexible control over thinking styles and promote the development of a new model of the significance and importance of thoughts and beliefs.

There are several differences and some similarities between DM and other mindfulness practices. DM is intended to impact on the CAS and enable the development of new metacognitive knowledge. The features and information-processing requirements of DM can be specified in the context of the metacognitive model.

Ten strategies for achieving DM as part of MCT were described. In MCT the therapist uses these techniques most often as part of the early sessions of treatment. They form only a component of the treatment process. They should not be considered as intensive training exercises or as procedures that determine the success of the intervention, but instead as useful tools that can be used to facilitate metacognitive change and the transition between cognitive and metacognitive levels (or modes) of working.