Mindfulness and Compassion in Psychotherapy
Clinical Integration, Evidence Base and Mechanisms of Change
In January 2021, The Awake Network and the Center for Mindful Self Compassion brought together 20+ leading experts in the fields of mindfulness and compassion-based therapies, neuroscience, and compassion training.
When Moment-to-Moment Awareness Isn’t Enough
by Chris Germer, originally published in Psychotherapy Networker, 2015
This is a mystery story, one that began several decades ago, with a single tear. The tear wasn’t mine, nor did it come from any of my clients. Instead, it rolled down the cheek of my first therapist as I impassively told him the story of my father’s leaving in the middle of my high school athletic awards banquet. Proudly, I’d returned from the stage after receiving my first varsity letter for soccer only to find my father’s chair vacant. My mother tried to excuse his behavior, but I knew my father had simply been bored and had left. I’d grown used to his inaccessibility and absence, a style of parenting all too common in his Mad Men generation, but my feelings this time were amplified by the shame of needing to find a ride home for my mother and myself.I’d tried to downplay the impact of this experience with my therapist, so when I glimpsed that tear trickling down his cheek my first thought was Whoa, this guy must have some serious father issues of his own.
But then something shifted inside me as I suddenly sensed that he was crying not for himself, but for me, for the anger and sadness I hadn’t allowed myself to feel in a long time. Soon I began to sob until the tears were gradually replaced by a sense of deep peace and connection.
My therapist and I didn’t talk much afterward about what that tear was about, but as I walked home, the warm summer night felt different, like a loving embrace.
Of all the hours I spent with my therapist, that one moment of wordless communion, feeling so completely understood and cared for, is the one that stayed with me long after just about everything else we said faded from memory. For many years, I had no language to describe what had happened or how it seemed to awaken something I’d never before known inside myself, altering the most immediate sense of what it meant to be me. And for years afterward, when I’d find myself lost or adrift, I’d return to that moment and feel a sense of kindness toward myself, however vague it was, which gave me hope for myself and for the profession I was beginning to learn about.
In some ways, that experience began a quest I’ve been pursuing ever since to understand the ineffable core at the heart of therapeutic healing and how I might learn to embody it in my own work.
Although I didn’t quite realize it at the time, all the models I was trained in as a young therapist in the 1970s—psychodynamic psychotherapy, cognitive and behavior therapy, strategic and systemic family therapy, several variations of group therapy, and whatever else was cooking in California at the time—despite their surface differences, shared the same underlying premise: something in the client was broken and needed to be fixed. I was taught that it was the therapist’s job—by interpreting defenses, changing dysfunctional thinking, or reorganizing family dynamics—to repair the damage. My own instincts, however, which I could barely articulate at the time, took me in another direction. Whatever model I was trying to follow, I naturally found myself moving toward offering comfort, support, and connection, sometimes to my supervisors’ amusement. The technical and theoretical issues that were the focus of my training, while intriguing to me, seemed largely irrelevant to what I thought mattered most in therapy.
I wasn’t entirely sure what I was doing in the therapy room, but something was propelling my clients toward sharing their most shameful secrets, often things they’d never told anyone else before. Sometimes they were subtle, like the quiet grief of a woman who no longer felt any desire for her husband, and sometimes they took a more dramatic turn, as with the anguished efforts of a man who’d struggled for years to disguise his sexual addiction and his paralyzing sense of shame about it. And quite regularly, initially to my great surprise, the people who shared their lives with me in this way wound up crying tears of relief, often for the first time in many years. All this made for intense experiences in my office, but beyond the expression of heartfelt emotion, I was never quite sure what happened once they left the session.
I didn’t know how to help them keep alive the connection with themselves that they’d made through their connection with me and transport their temporary sense of well-being, however authentic it may have been, back into their lives on an ongoing basis.
In search of clues about what might help people sustain a healing frame of mind between sessions, I reflected back on my earlier training in self-hypnosis and meditation. In self-hypnosis, I came face-to-face with the underlying reason that so many clients remain stuck in their problems despite their most strenuous efforts to change: what we resist persists. Whenever I told myself in self-hypnosis that I was becoming calmer, the opposite occurred. I couldn’t get out of my own way, and the harder I tried, the worse it became. But my experience with meditation was different, offering an alternative pathway to calming the mind that avoided the pitfalls of self-hypnosis. I discovered that meditation didn’t involve trying to feel anything different or making myself achieve some elusive goal. All I had to do was gently return my attention again and again to a mantra or the breath, no matter what I was thinking, feeling, or hoping would happen. There was no way to fail, and the impact on me was powerful.
I’d always been a bit obsessional, with a natural tendency to hunker down and contract around whatever I focused on. That’s helpful for doing things like becoming a PhD psychologist or finishing a dissertation, but not so great for managing stress and anxiety. In fact, when I first began meditating on the breath, I discovered that the more willfully I tried to focus my concentration, the shorter and shallower my breaths became. Sometimes, I even found myself gasping for air. Eventually, it dawned on me that if I softened my attention and just allowed myself to enjoy my whole body, rhythmically moving with each inhalation and exhalation, my breathing would take care of itself very nicely (thank you very much!). Over many years, learning to pay soft attention to my breath allowed me to be focused and productive in my life in a spacious, more enjoyable way. It changed my way of being.
I began to meet with a group of colleagues, most of whom were psychodynamically oriented, who were developing their personal mindfulness practices and wondering how best to introduce the benefits of mindfulness meditation to clients. We were exploring the aspect of mindfulness known as choiceless awareness, allowing ourselves to notice, moment by moment, anything salient and alive in our field of awareness—tension in the gut, an image from childhood, a wisp of desire, a moment of fear. Most of us had already realized that, generally speaking, our clients didn’t come to therapy for instruction in meditation techniques and resisted it if we offered it directly. Rather, they were seeking to be heard and understood in a different way, and the less mention of formal mindfulness practices, the better. Perhaps the way to teach mindfulness was to offer our clients the potentially transformative experience of being listened to in a deeper, more mindful way, through our therapeutic presence—being open to what was arising in the present moment, physically, mentally, emotionally, and relationally.
I remember the excitement of beginning to explore this therapeutic pathway and thinking that it might offer the solution to the mystery of what exactly had opened up in me when my first therapist had shed that tear.
Certainly, he’d been more present with me than I was being inside myself, and I became intent on being more fully present with my clients in a similar way.
Paul, for example, came to see me after his girlfriend had unceremoniously dumped him. In our work together, he’d taken care to understand his ex-girlfriend’s motivation and how she’d struggled in the relationship. On this day, however, he was ranting about how she’d manipulated him and cast him out of her life “like a sack of stinking fish.” As he spoke, I felt my abdomen tense up and noticed myself becoming annoyed with him. I felt the impulse to argue that his ex-girlfriend couldn’t possibly have been so deliberate about manipulating him, but I knew that would’ve led to an empty, unproductive struggle. I realized that the best way to get unstuck from his rant was by using my own sense of presence to help him become more present to what was happening inside him.
I checked in with my experience of our interaction, felt his anger and frustration in my body, and realized that I was feeling the same things: we were in an emotional contagion. “Are you feeling angry today?” I asked. “I wonder if you’re finally allowing yourself to be angry.” Taken off guard, he quietly agreed, and the tone of the session changed completely. The potential standoff between us shifted into an opportunity to explore together how Paul’s allowing himself to feel the full pain of this breakup could expand his awareness of what had happened and the possibilities he might discover in future relationships.Around that time, mindfulness had begun to enter into the therapeutic mainstream. The emphasis in cognitive behavior therapy (CBT) was shifting from a fix-it agenda, focused on changing how clients think and feel, to helping clients cultivate a more hospitable relationship to their thoughts and feelings. To alleviate depression, clients were being taught to observe their thoughts and recognize that they weren’t facts. Alcoholics were given the skills to watch the rising and falling of urges—to “urge surf”—rather than reach for a drink. People suffering from anxiety were encouraged to commit themselves to their deepest values and taught how to accept the arising of anxiety along the way.
I, too, was finding more ways to apply mindfulness in the relational therapy I was already doing with clients like George, a 25-year-old man with a history of obsessions and compulsions, who’d come to therapy because he was having thoughts of harming his newborn daughter with a knife. Although he and his distressed wife had removed as many sharp objects from their kitchen as they could, new means of harming his child continued to pop up in his mind.
As George explained the situation, I first felt truly frightened that George was a genuine danger to his child and could feel the fearful energy coursing through by body. But once I named it—oh, fear—I started feeling sad for George. As I calmed myself, I began to see how desperately he wanted not to harm his child. So I asked him, “George, do you want to hurt your child or are you afraid you’ll hurt your child?”
“I would never want to hurt my child!” he replied. We then discussed how he was confusing his fear with an intention to harm, and we explored together how he might separate the two. George came up with the idea of counting how often during the week he felt afraid and how often he genuinely wanted to hurt his child. At our next session, he reported in a bemused way that he was often afraid, but never once wanted to hurt his little girl. Whenever the fear arose, he said to himself, This is fear, fear, fear . . . and took a deep breath. Cultivating mindful presence in both myself and George had transformed a case fraught with the darkest apprehensions into a shared exercise in exploring the mindfulness of intention and developing a therapeutic alliance based on shared awareness. This seemed to be a much more effective approach to teaching mindfulness in therapy than formal mindfulness meditation.
Beyond Moment-to-Moment Awareness
For years, mindfulness became the guiding force in my life and clinical practice. But while I regularly saw its benefits with my clients, over time I became more aware of the limitations in how I was applying it and how it seemed to be understood in the therapy community.
I could see that the people in my practice generally improved and achieved a greater sense of calm and balance in their lives, but I suspected something was missing.
I kept remembering my experience with my first therapist and wondering how I could learn to offer a deeper experience that could enter the very fiber of a person’s being and stay there. It took a personal crisis for me to see what I’d been missing.
Despite practicing meditation and being in therapy most of my adult life, I continued to be dogged by debilitating public-speaking anxiety. In the run-up to just about any speech I was to give, my heart started pounding, my hands began to sweat, and I found it harder and harder to think clearly. To counter this anxiety, I tried everything I could think of—meditation, acceptance strategies, diaphragmatic breathing, strenuous exercise, beta blockers, you name it—but nothing worked. Of course, as a therapist trained in cognitive approaches, I knew that sufficient exposure was eventually supposed to desensitize my fears. So I accepted every speaking gig that came my way and tried to tough it out, but without much effect. Once, while I was giving a talk in Santa Fe, my anxiety got so bad that a well-meaning audience member called out from the back of the lecture hall, “Take a breath!” I was supposed to be talking about the benefits of mindfulness, and I could hardly utter a word.
Not long afterward, I was scheduled to speak at a Harvard Medical School conference that my mindfulness colleagues and I had organized. I’d been safely tucked in the shadows as a clinical instructor on the faculty of the medical school for many years, but this gathering meant that I’d have to stand up in front of a huge crowd and be seen in all my stumbling glory. With four months to go before the conference, I went on a silent meditation retreat from which there was no escape from my fears. Whenever my mind wandered to the upcoming conference, I could feel my body surge with anxiety at the prospect of making a fool of myself. No amount of holding it in spacious awareness alleviated my distress.
Eventually, I had an interview with an experienced meditation teacher running the retreat. I sheepishly reported my failure to meditate and the content of my distress. She flashed a sweet, knowing smile and then offered a suggestion so simple that it was almost mortifying to think that I’d not yet done it on my own. “Just do loving-kindness meditation,” she said. “Repeat the phrases ‘May I be safe. May I be happy. May I be healthy. May I live with ease.’” That was it.
Willing to try anything at that point, I returned to my cushion in the meditation hall and immediately began repeating the phrases. In spite of all the years I’d spent familiarizing myself with all the nooks and crannies of my inner life, I’d never spoken to myself in that tender, comforting way.
Right off the bat, I started to feel soothed. It even occurred to me that maybe I was cheating—aren’t retreats supposed to be hard?—until I realized that something had loosened up inside me and I could feel my breath again.
During the breaks in the retreat, the world became alive in a new way. I could actually see the people around me and savor the beautiful surroundings of the retreat center. It was as if someone had opened the door to a different level of more expansive awareness.
When I got home I adopted loving-kindness as my primary meditation practice, and whenever I felt anxiety about the upcoming conference I just said the loving-kindness phrases to myself, day after day, week after week. I didn’t do this just to calm myself down, but simply because I needed a little kindness and understanding for my problem. Finally, the day of the conference arrived. When I was called to the podium to speak, the usual fear rose up within me. But this time, there was something else—a little delight, a twinge of excitement, and a sweet background whisper saying, “May you be safe. May you be happy. . . .” Then I looked out over the crowd and thought, “Oh, may everyone be safe. May everyone be happy. . . .” At that moment, joy rose up in the place of fear.
I’ve often reflected on that moment. I think the reason that, earlier on, I couldn’t accept my anxiety and let it flow through me was that something deeper was blocking me. My public-speaking anxiety wasn’t an anxiety problem at all: it was a shame problem. Whenever I imagined myself at the podium, trembling and unable to speak, I saw myself being humiliated in front of my esteemed colleagues, perceived as incompetent, or even fraudulent, and I just shut down.
But as I continued in the practice of loving-kindness meditation, I felt as if a supportive friend had my back. Kindness resonated through me, even as I sensed the shame I’d been carrying around most of my life.
Throughout the months running up to the conference, I started to see my self-doubts not as facts, but as ideas that had been dancing in and out of my life. I was beginning to learn self-compassion.
Granted, I still get anxious before an important presentation, but when it happens, I can now allow the images, fears, and shame to course through my body. Then, when I put my hand on my chest, my heart softens a little bit, and I say kind words to myself, such as “This hurts. This is what shame feels like. You’re a good man.”
Through the Eyes of Self-Compassion
Definitions of a highly subjective state of mind like compassion can sometimes become murky and abstract. That’s why I prefer the simple Buddhist definition: “When love meets suffering and stays loving, that’s compassion.” Compassion is a deep feeling for a suffering individual with the wish and effort to alleviate it. And self-compassion is compassion directed toward oneself; it means treating ourselves with the same kindness and understanding with which we’d want to treat someone we truly love.
In my own case, why did self-compassion prove itself to be so helpful, despite years of meditation, when it came to dealing with my public-speaking anxiety? The answer lies in key differences between mindfulness and compassion. Mindfulness, as it’s typically understood nowadays, focuses on closely observing moment-to-moment experience, whereas compassion focuses on an inner relationship to the experiencer— our often-beleaguered sense of self.
When we’re overwhelmed with intense and disturbing emotions, such as shame, just noticing what’s happening is often not enough. We need to embrace ourselves.
While mindfulness tells us, “Hold your suffering in spacious awareness,” the wisdom of self-compassion says, “Be kind to yourself when you suffer.” Self-kindness opens a new path to healing. Warmth creates space. Mindfulness invites us to ask, “What am I experiencing right now?” Self-compassion invites us to ask, “What do I need right now?”
After my experience with public-speaking anxiety, I decided to explore whether self-compassion could enhance the mindfulness-based treatment I was offering my clients. I’d already been treating Meryl, a 55-year-old mother of two grown children, for about a year. She’d come to therapy with chronic lower back pain. She was somewhat embarrassed to admit that masturbation would alleviate the problem for a few hours, but it got her into an annoying cycle of back pain and seeking relief through masturbation. As she described her situation during the intake interview, I could feel her sense of vulnerability in my own body—which led to a conversation about how uncharacteristically fragile she felt with back pain. I wondered aloud if masturbating made her feel safe. The idea intrigued her, but she wasn’t sure.
Meryl decided to explore the matter for herself over the coming weeks. Whenever she had back pain, rather than resenting it and masturbating to make it go away, she’d let herself experience the physical sensations and ask herself what emotions she was feeling at the time. She couldn’t identify any specific emotion associated with back pain—sometimes it was fear, anger, loneliness, or sadness—but much to her surprise, the pain subsided when she looked inward and explored her experience. When I asked how she understood that, she replied, “I guess I just stopped turning away; maybe my body just let go.”
From a mindfulness-based perspective, Meryl made progress because she’d stopped resisting back pain (“What we resist persists”) and had turned toward it with curiosity (“What we can feel we can heal”). She complained, though, that she still had to soldier through the pain before she found relief, and sometimes it didn’t work. Therefore, our new compassion-based approach focused less on making space for pain and more on a compassionate response to it—asking herself the quintessential self-compassion question, “What do you need?”
Apparently, no one had asked Meryl that question before. She shared with me that she’d been raised on duty, hard work, and sacrifice. Her relationship to her back pain was a struggle. “When it comes up,” she said, “it’s always ‘Ugh, grrr. I’ve got it again. This is terrible.’” So I thought perhaps she needed to warm up the conversation (to use a phrase from Paul Gilbert, a leading pioneer in compassion-based therapy), and I asked her what she’d love to hear whispered into her ear when she was in pain. Meryl took a moment, smiled broadly, and said, “Oh, I’m so, so sorry you’ve got pain again!” Sensing the tenderness in those words, Meryl committed herself to saying them whenever she needed to. Sometimes she put a hand on her chest to reinforce the attitude of warmth and kindness, asking herself, “What else do I need right now?” Quite often the answer was to say no to family obligations. Meryl told me that this new way of being with herself made it much easier to accept and release back pain when it arose. She definitely smiled more in our sessions. She even started embracing her back pain, calling it a “self-compassion bell” that reminded her to be kind to herself.
The Promise of Self-Compassion
Throughout the history of psychotherapy, from Freud to Carl Rogers, self-acceptance—an umbrella term that includes self-compassion—has been highly valued and considered an essential by-product of the therapeutic relationship. But what most therapists haven’t understood until recently, myself included, is that we can give compassion directly to ourselves. Nevertheless, for decades, we’ve been implicitly teaching self-compassion to our clients in talk therapy without knowing it. In fact, the nonspecific effects of therapy, the so-called placebo effects that increasingly show up in research as being more important than technical or theoretical factors might well be attributed to self-compassion—teaching clients how to turn toward themselves with interest and kindness.
Could it be that the development of a client’s self-compassion is the invisible mechanism that best determines whether therapy sticks and transforms a person’s life?
Only future research will help us determine whether learning self-compassion, an inner relationship that mimics the outer therapy relationship, will help us learn how to make therapy more portable outside our session with clients and with more enduring effects. My guess is that it will.
With the rapid proliferation of new therapies for every possible difficulty in life, it often seems that we’re trying to do the impossible—eliminate basic human suffering. But suffering doesn’t seem to go away, no matter how many therapies or self-help strategies we employ. Most of us die with our neuroses intact. As meditation teacher Rodney Smith says, “All techniques are destined to fail.” So what’s left for therapists to do if we accept this proposition? Perhaps our capacity to be truly therapeutic begins when compassion takes center stage.
Of course, even self-compassion is sometimes guaranteed to fail. For example, if you suffer from insomnia and comfort yourself during a sleepless night with loving-kindness phrases, you may initially be able to doze off. Then you say in the morning, “Wow, this works!” But the next time, it doesn’t work at all. Why? The problem isn’t in the technique but in the intention behind the technique. During the first go-around, you practiced self-compassion for its own sake, simply out of visceral sympathy with your own suffering, but the second time around, your motivation subtly shifted into yet another struggle with your experience and yourself. Ultimately, that can’t work: what we resist persists. Being truly compassionate is a spontaneous outpouring of the heart, much in the way a devoted parent might respond to a child with the flu. The parent isn’t being compassionate so as to drive out the flu. The heart just melts.
Sometimes we worry that if we allow our hearts to melt in response to our own suffering, it’ll make us weak and lead to self-pity and self-indulgence. Ironically, the rapidly expanding research on self-compassion shows precisely the opposite. As Carl Rogers famously wrote, “The curious paradox is that when I accept myself just as I am, then I can change.” But I think that meditation teacher Rob Nairn said it best: “The goal of practice is to become a compassionate mess.” That means accepting our full humanity—often struggling, uncertain, vulnerable, and confused—but with great compassion. It might just bring out the best our profession has to offer.