Mindfulness in Psychiatry: How to Teach It as a Clinical Treatment Skill

Summary

Psychofarm Podcast Episode Summary

Episode Title: Mindfulness in Psychiatry: How to Teach It as a Clinical Treatment Skill
Date: May 5, 2026
Hosts: Dr. Fu and Dr. Malsberg

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Overview

This episode explores mindfulness as a core clinical skill in psychiatric treatment. The hosts, both practicing psychiatrists, break down how mindfulness transcends its spiritual roots, its integration into modern psychiatric modalities, best practices for teaching it to patients, and its applications and limitations across various psychiatric diagnoses. The episode is practical, candid, and sometimes humorous, designed for clinicians and curious mental health enthusiasts alike.

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Key Discussion Points & Insights

1. Mindfulness as a Medical Treatment

• Not Ritual, but Treatment: Mindfulness is positioned firmly as a legitimate medical treatment, not just a spiritual or self-help practice.
• Patient-Centered: Unlike medications that are "done to" patients, mindfulness is something "the patient has to do" as part of their recovery.
  • "You should and can consider mindfulness to be a medical treatment. It is a treatment that the patient has to do rather than something you do to the patient." — Dr. Fu [01:59]

Defining the Medical Model

• The episode riffs on the "medical model," emphasizing that anything customarily practiced and prescribed by medical professionals for a medical problem can be considered medical.
• Mindfulness should be in the clinician's toolkit alongside medications and structured psychotherapies like CBT and Behavioral Activation.

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2. The Secular Roots and Universal Relevance of Mindfulness

• Beyond Religion: Although mindfulness has religious and cultural roots, particularly in Eastern traditions, the hosts make the case that mindfulness is a universal human capacity, present in every culture.
  • "I don't see this as a religiously based practice, even if there is a tradition within religion." — Dr. Fu [03:52]
• How It Entered Western Psychiatry:
  • The "waves" of psychotherapy: from behaviorism (targeting behaviors) to CBT (including thoughts), to "third-wave" therapies like DBT and ACT that integrate mindfulness.
  • Reference to Marsha Linehan's development of DBT after studying Zen, and Jon Kabat-Zinn's Mindfulness-Based Stress Reduction.

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3. Working Definitions & Core Elements of Mindfulness

• A Constrained Working Definition:

  • Deliberate attention
  • To the present moment
  • Without judgment
    (“Deliberate attention to the present moment without judgment.” — Dr. Fu [09:03])

• Why It Matters:

  • Disrupts ruminative cycles—often seen in anxiety, depression, and trauma.
  • Shifts focus from default mode network (associated with self-reflective, ruminative brain states) toward more adaptive, present-oriented processing.
  • Fosters "cognitive defusion"—the ability to observe thoughts as transient events, rather than as self-defining truths.

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4. Indications and Contraindications for Mindfulness Practice

Indicated For:

• Generalized Anxiety Disorder (GAD):
  • "I give it grade A in regards to recommendation for mindfulness. I think, I think this is almost like you're a requirement for teaching for patients with generalized anxiety disorder." — Dr. Malsberg [22:23]
• Major Depressive Disorder:
  • Useful, especially for chronic or recurrent depression, but must be paired with biological treatments for acute episodes.
• Personality Disorders (esp. Borderline/Cluster B):
  • DBT hinges on mindfulness as a cornerstone skill for long-term improvement.
• Substance Use Disorders:
  • Mindfulness can create a "space" between urges (e.g., for substance use) and actions, common in various addiction programs.
• Complex Trauma & PTSD:
  • Mindfulness needs modification (use grounding techniques; avoid practices that risk retraumatization).

Cautions/Contraindications:

• PTSD:
  • Traditional ("sitting" or meditative) mindfulness may retraumatize; require adaptation using grounding strategies.
  • "Mindfulness on its own can actually be, can be harmful to the patient. So it really depends on the particular patient." — Dr. Malsberg [24:07]
• Acute Distress:
  • Avoid introducing mindfulness during episodes of crisis, dysregulation, or intense distress (above 7/10 on a subjective scale), as it may not be effective and could backfire.

Universal Benefit, Individualized Approach

• Mindfulness is likened to exercise—helpful for everyone, but the type, intensity, and goals should be personalized.
  • "It's like exercise. It's for everyone, but it's for everyone in a different way." — Dr. Fu [27:08]

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5. How to Teach Mindfulness as a Clinical Skill

General Principles

• Mindfulness Should Not Be Distressing or Effortful:
  • Start simple, avoid inducing discomfort, and keep expectations minimal and clear.
  • "It should not be unpleasant. It should not be significantly effortful. It should not be a struggle." — Dr. Fu [31:16]
• Avoid Over-Reliance on Technology:
  • Apps and videos are okay starters but ultimately, patients should practice independently and in varied contexts. [33:05]

Step-by-Step Teaching Approach

1. Psychoeducation:

   • Explain what mindfulness is (see 3-part definition), its purpose, and clarify common misconceptions.

2. Set Realistic Practice Goals:

   • Suggest a tiny, concrete goal to start (e.g., 5 minutes once a week at a scheduled time).
   • "All I need is something like five minutes once a week. What do you think?" — Dr. Fu [36:19]

3. Provide Simple, Varied Exercises:

   • Use DBT mindfulness handouts as accessible resources (publicly available online, e.g., Kaiser Permanente's DBT Mindfulness PDF).
   • Encourage patients to pick from a menu of exercises:
     • Sitting/counting breaths
     • Naming objects around them
     • Observe, Describe, Participate skills ([44:09]–[45:01])

4. Normalize Failure and Celebrate Trying:

   • Emphasize it’s normal if practice is inconsistent or doesn’t “work” immediately.
   • Avoid rigid “homework” dynamic—make practice low-pressure and tailored.

5. Striking "When the Iron’s Cold":

   • Practice mindfulness during calm times, not in acute stress, to avoid associating the practice with distress.
   • "The goal of this isn't, is to practice when things are calm and easy so that it helps during the more stressful periods." — Dr. Malsberg [40:11]

6. Follow-Up:

   • Check in neutrally on the patient’s experience and challenges.
   • De-shame if they “didn’t do their homework”—avoid judgment.
   • Reiterate that benefit is cumulative and long-term, not immediate.

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Notable Quotes & Memorable Moments

• "Anyone can say they're eclectic... I pick and choose what's good. There's nothing wrong with that on the face of it. But... people may call themselves that and they don't necessarily... and then they do nothing." — Dr. Fu & Dr. Malsberg on "cafeteria psychiatry" [08:11–08:34]
• "We really think of our thoughts as who we are... Mindfulness, I think of taking a step back and instead of viewing these thoughts as me, as I, viewing these thoughts as a process that's occurring within the true me." — Dr. Malsberg [13:33]
• "With mindfulness, no one who does it to get better will ever get better, because what they're getting better from is the someone who wants to get better." — Dr. Malsberg [21:05]
• "If you try to practice mindfulness with a particular outcome in mind, it will subvert the efficacy of the practice itself. The process over content mantra is just as relevant." — Dr. Fu [19:00]
• "If you want to practice mindfulness, just Google 'DBT Mindfulness PDF'—the first thing that comes up is Kaiser Permanente. Click that one..." — Dr. Malsberg [41:51]

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Timestamps for Key Segments

• [01:59] – Framing mindfulness as a medical treatment
• [03:52–07:50] – Origins of mindfulness in psychiatry
• [09:03] – Clear working definition: "Deliberate attention to the present moment without judgment"
• [11:25–13:33] – Mindfulness as a response to ruminative and ego-based thought patterns; neuroscience basis (Default Mode Network)
• [16:44–21:58] – Goals of mindfulness and paradox of seeking outcomes
• [22:23–30:08] – Diagnostic indications/contraindications, grading the evidence and clinical utility per condition
• [31:16–33:59] – Warnings and pitfalls when introducing mindfulness
• [34:14–41:51] – How to teach: scripts, handouts, demonstrations, scheduling, patient buy-in
• [41:51–47:55] – Practical tips: favorite handouts, troubleshooting, monitoring progress, CBT-style check-ins
• [48:39–49:55] – 'Skillful Means' and 'right diagnosis, right treatment' as guiding philosophies

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Final Pearls & Takeaways

• Mindfulness is a flexible, fundamental tool for psychiatric care—akin to physical exercise for the mind.
• Start with clear, simple instructions and normalize struggle/failure in practice.
• Personalize techniques to the patient’s needs, diagnosis, and readiness.
• Avoid making mindfulness a distress response tool; instead, cultivate it as a general coping and awareness practice.
• Utilize widely available DBT handouts and simple scripts to give patients accessible entry points.
• Checking in supportively and non-judgmentally is critical for long-term adoption and effectiveness.
• Teaching mindfulness is a skill in itself—develop your own toolkit, keep it empathic and pragmatic.

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For more resources, links to handouts, and related material, visit psychofarm.substack.com.

Transcript

[A]

Good morning, Dr. Malsberg.

[B]

Good morning. How's it going?

[A]

Oh, not too bad. I think I'm feeling better this episode because at the minimum, I have some Gremlins or Ewoks or whatever you want to call it. Hopefully that doesn't get censored by lucasarts cheering me on in the middle of the podcast. You know, it feels good. And they're kind of like, mm, yeah, I'm listening. It's good stuff.

[B]

We should probably explain that for the. The non. The listener who doesn't listen to every single episode. There were Gremlins Ewoks in our last two episodes.

[A]

Two. Or was it one? I don't know. I only heard in one.

[B]

I do the editing for the podcasts and I don't know what I'm doing. I have no. No background in audio. And fixing the levels is the pebble in my shoe. I do not know how to do the levels. It's so much more complicated than it sounds like. So I've gotten tons of feedback that we need to fix the levels in the podcast. So then I use Adobe podcast, I use some filter to do the levels, but apparently that makes it so that there's little Gremlins and little Ewoks just chirping around in the background. Occasionally there's some moans that sound somewhat sexual.

[A]

Well, I think that's your projection. I think it's just moans of understanding.

[B]

I think, unfortunately, it's probably going to happen again this podcast. So Dr. Fu might have some Ewoks in his apartment.

[A]

Yeah. I would like to hear if people prefer having the little gremlins in the podcast or if they prefer the poorly leveled, unplugged 90s feel of the previous episodes. So leave it in the comments.

[B]

And those are your only two options, because a properly produced podcast is not one of the options right now.

[A]

Yeah, certainly not with our current user base. So what is the topic today?

[B]

I believe the topic today is going to be mindfulness.

[A]

Oh, yeah, big topic. I fear, again, one that people will have a tendency to neglect in our very medicalized, medicine focused world. But I want to emphasize at the outset here that you should and can consider mindfulness to be a medical treatment. It is a treatment that the patient has to do rather than something that you do to the patient. But you should consider it as one of your treatment options. That that's a strong belief of mine.

[B]

Now, when you say it's a medical treatment, what do you mean by that?

[A]

Well, then that raises the big question of what is a medical problem. Right. And we're going to go the tautological route that a medical problem in the medical model is what physicians customarily do. Okay. Whatever that is. This is not an original idea, by the way, and I can't remember who it was, though. I apologize. There's a. I think it was an analytic or a traditional psychiatric thinker who originated this medical model. If you Wikipedia it, you'll find him. And then, therefore, a medical disorder is one that is found through the medical diagnostic process and is customarily treated by medicine people. That's it. Okay. And mindfulness, like anything else, is an intervention that in my opinion, you should be reaching for, thinking about, and counseling about. Similar to, for example, CBTI or Behavioral Activation. Your options are not just medication prescriptions. You should and can prescribe treatments like mindfulness.

[B]

So mindfulness can mean a whole host of other things, and it also has associations with religion, especially like Eastern religion. Can you, can you talk a little bit about how you, how you view it?

[A]

Yeah, I mean, that's an important thing to address at the forefront. I would say we can't ignore that mindfulness comes from traditional religious and cultural practices. Right. Especially of the East. But I. I think what we should recognize, and I would advocate for this, is that it's not something that's restricted to a particular faith or religion, even if one of the major origins is religious in nature. I think that if you really drill down to what mindfulness actually is, you're going to find that it's a common traditional practice in pretty much every major culture, or perhaps every culture at all. It's a very, very human capacity and experience. So that's number one thing. I don't see this as a religiously based practice, even if there is a tradition within religion. And why is that? Well, I would argue that religion was simply the organizing culture of spirituality and higher order beliefs up until very recently in human history. Not that I'm an anthropologist or anything. How did we get from traditional behavioral therapy to mindfulness? That's something that we might want to paint out. Did you ever encounter sort of the just so story of the progression of Western psychotherapy across the 20th century? What's your take on it, if you have any?

[B]

I don't know if I'm not quite sure if you're referring to something specific. I have two, two examples of it really coming in. There's the wonderful origin story of Marsha Linehan, who was struggling with borderline personality disorder, went and studied some Zen Buddhism and then developed DBT out of this combination of behavioral Therapy and the Zen tradition of mindfulness. And then you also see it, I think, the third wave cbt, especially acceptance and commitment therapy, a large portion of that is founded on mindfulness.

[A]

Yeah, I mean, either one is probably worth a mention. But I guess the broad strokes thing that I want to point to is that outside of the psychoanalytic realm of things, you originally had the behavioralist. Right. And again, this is a just so story. This is like a really broad strokes version of the history. So, you know, it's not official, but originally there are people that were modifying behaviors in the psychology community. Then they had the idea to bring in thoughts. Right. Not just behaviors, but thoughts. So that got us to cognitive behavioral therapy. And of course, affect was integrated at one point in there, even though I think it's still a little de emphasized, except as a means of analyzing thoughts. And then around the time, in the 80s, it was, I believe, Kabat, Zinn and other people in this group that were researching mindfulness based stress reduction treatments or practices, and they started to see that this was efficacious for certain mental disorders or mental distress. And yes, there was also the DBT movement as well. And by the time we get past the 80s, mindfulness is pretty much a scientifically established and well integrated into therapy practice, technique or set of skills. You know, so it is a broad thing, and I think as of today, it's very much separated from the religious underpinnings or rather the history. And you shouldn't just consider it as a medical treatment when you are using it in the framework of being a physician or therapist.

[B]

Yeah. And there's even the specific modality of mindfulness based cognitive therapy, mbct. But I agree in terms of how I think about practicing psychiatry, not that I like the idea of eclectic therapists or anything, but essentially you can pick and take the helpful things from each of the different modalities and then integrate them into your practice.

[A]

Yeah, I mean, eclectic, I think is a problem because anyone can say they're eclectic. Right. I'm a cafeteria therapist or I'm a cafeteria psychiatrist. I pick and choose what's good. I mean, there's nothing wrong with that on the face of it. But I think the issue is that people may call themselves that and they don't necessarily what's up?

[B]

And then they do nothing.

[A]

Right. They may not adequately consider or have knowledge about the basic theory and concept and the frame of how these kinds of different techniques and therapies are utilized. So that's kind of this hopefully will be a little episode That's a primer, but it's by no means complete.

[B]

So let's jump into it so that people do have an idea of these things. Talk to me. What is mindfulness?

[A]

So this is another umbrella term. Just like schizophrenia is an umbrella term, bipolar is a umbrella term. You know, mental health is an umbrella term. So keep that in mind. Lots of things say their mindfulness. I want to make a very constrained definition of mindfulness here because I think it is, has all the necessary and sufficient conditions that will help patients get better or at least have less distress, okay? So for me, I would say that there are three necessary and sufficient parts to mindfulness practice, okay? So it is a practice. It is something that you do, okay, actively. Not just something that you experience, not just something that is done to you as the subject. But part one is deliberate attention, paying attention on purpose, okay? Part two is to the present moment, okay? It's deliberate attention to the now, the ongoing now, not the future, not the past, not what could be, not what could, not what should be. Okay? And then part three is without judgment, okay? And that includes not judging yourself for judging or falling out of a mindful state while you're trying to practice it. And there's a practice, it's practice because you fail. Right? That's why we call it practice. So again, deliberate attention to the present moment without judgment.

[B]

I really, I think you talked about this, the three parts in a previous podcast, and then I started using it because it's such a helpful way to explain it that's very simple and easy to remember. And when I explain things to patients, it needs to be super duper simple. You don't want to add all these other layers of Buddhist thought and your own experiences of mindfulness because it can be too confusing and complicated. And the way you put it here is just super duper simple. Now, can you give us a little bit more color as to what you mean by these three things? So is this something that I do all the time? Is this something that I pick a few minutes to do? Why am I doing this? When you say mindful, why is attention to the moment for full of mind?

[A]

Yeah. You know, not getting stuck too much into terminology. I think we can highlight why this is important. Right? Let's just take the example of anyone, any kind of ruminations. The ruminations can be trauma related, they can be anxiety related, they can be obsessions and compulsions. They can just be simple worries that would be common to any person. Right? But if you are ruminating, you are living and Experiencing your own thinking. Right. You are paying attention to the words or symbols or fantasies in your head and not the outside. You are also probably focusing your attention on what could be, what should be the future or the past. This is generally speaking not a particularly pleasant experience when it's kind of overdone. Right. And we generally do agree that when you're doing too much of this, it's a pathological state and we have various names for it for the particular subtype in the dsm. We should note here that we actually have some preliminary neural neuroscientific research on this. Right. And it's the default mode network. We've discovered that people in sort of self facing, overly ruminating or introspective or depressive states seem to be in a brain state. We can call it a brain network state where they just have a certain activity pattern. We call that default mode network. And that is associated with certain unpleasant states or disease states. And then when you start to pay attention to something outside of you or the present moment, then that kind of pulls you out of the default mode network. And that's associated with other long term changes that we're probably not going to get into. Unless you have something to add for that off the top of your head. I don't have it off the top

[B]

of my head, not on that specifically, but I'll say what you said and maybe different, different language and just as another perspective or I mean probably saying the same thing. But we really think of our thoughts as who we are. And in like the Eastern tradition, what they call the ego, which is different from the psychoanalytic ego. That's the idea of who I am. My likes, my dislikes. Dr. Malsberg is a psychiatrist. He likes the color blue. He gets upset about XYZ and our internal monologue. It's always commenting on things and judging things and planning things. And it contains a lot of self thoughts like oh, I like this, this is what I want. I want this to go a particular way. And there's especially in. It's very common to confuse that as that that's all that we are. And we kind of get lost in our thoughts and think that our thoughts are everything that there is to experience. And when I think of mindfulness, I think of taking a step back and instead of viewing these thoughts as me, as I viewing these thoughts as a process that's occurring within the true me. So when I'm practicing mindfulness, experiencing thoughts as a process. And that's because we normally deeply identify with thoughts and we get sucked into the melodrama of like in New York City, someone cuts me off and it's like oh this, that jerk off. Like this always happens to me. I'm always 15 minutes late. I just want to be on time and this. And you kind of get sucked into these common patterns of thinking. And when you're being, when you practice mindfulness, you're able to take a step back and you're to able view these things as a process and gives you a lot more of the ability to see how our thoughts naturally work and how certain things set us off and put us into certain mindsets. You mentioned the Default mode network. It's funny, I think a lot of psychiatry comes full circle in that these things were discovered by either religion or poets and then thousands of years later we kind of just repeat the exact same things that they were saying back then, except in a scientific language. But yeah, the default mode network is essentially that ruminative brain network. When you're not doing something, you pretty much naturally start thinking of problems in the past, thinking about who you are. And that Default mode network can cause a lot of problems. Just a small plug to leave a review if you can. Leaving a review will help other clinicians find our show and will let us keep making it. If you're on Apple podcasts, open the show page, scroll to ratings and review. If you like us, tap five stars. If you're not sure what to put for the review, just say, hi Dr. Fu. And if you're on Reddit or YouTube, leave a comment. Dr. Fu reads absolutely every single one. Let's get back to the show.

[A]

I think we should mention though we're not advocating that you should or should not be always in a particular state. I do think that a lot of the traditional religion aims towards that. I think that's probably wrongheaded and really what we're looking for is capacity building and flexibility. Right? You should be able to deploy a certain variety of experience or action for yourself when it is helpful to you. Right? That's what we're really getting at. And you know, you said that you were going to say the same thing, but I think you highlighted something very different from what I was saying that is equally important. And it's that we can at least concretize two goals of mindfulness practice, if you will. One is separation of your experience from your own thoughts and process, the ability to observe yourself, to self reflect. This is also captured in other terminology like ego syntonic versus ego dystonic or the observing ego. I'M sure there's also CBT terminology for it. Maybe it's examining your own thoughts or something like that. And then also essentially combating ruminations, worries, anxiety, and inward focus by going into outward focus. Both of these can be achieved by a more consistent mindfulness process practice.

[B]

Absolutely. I'm glad you bring that stuff up. I think of, like you said, mindfulness allows us to take a step back and watch the process rather than identify with the process. And I also you mentioned, like, we're not trying to attain a particular state or get to somewhere. So the goal. Some people think of mindfulness as like, you're stopping the mind or you're stopping thoughts, or you're experiencing pleasant thoughts or pleasant experiences. And that's not what mindfulness is. So to me, if you were to say there's a goal or something you're trying to accomplish with mindfulness, it's practicing so that you can start to understand the nature of your mind and understand how it works. And then when you practice in just short bursts a little bit every day, you have a little bit more space to react to the stuff that comes up and you don't identify with the emotions or thoughts and you don't get sucked into them as much as.

[A]

Yeah. Oh, the terminology I was thinking of, that I had just forgotten was cognitive defusion is probably the best CBT terminology for what you were referring to. Yeah. And what you're talking about here, I think we need to emphasize it's not an outcomes focused practice. If you try to practice mindfulness with a particular outcome in mind, it will subvert the efficacy of the practice itself. The process over content mantra is just as relevant, if not acutely relevant, for this scenario. It actually reminds me of something that I wanted to figure out. How to communicate in a way to interns that they would remember for four years. A lot of PGY4s, not a lot. A minority of PGY4s find themselves with the board exam staring them in the face a few months later. And they may not be as good at the tests as some of the other residents. And then suddenly they're like, what should I be studying so that I can improve my board test performance? The fact is, the journey of psychiatry training is not to do a test right. And if you're finding yourself in that situation, you may be a little late on the game. Really, the best way to prep for the board exam is to put yourself fully into the practice of psychiatry and read and study and research about everything that you run clinically across a four Year period. And then if you're at the end there and you're just looking at a board exam, it's going to be suboptimal compared to having been in that process the whole time without targeting, passing the board exam. And so it's the same thing in mindfulness. If you target getting better, having less distress, being more powerful, being more enlightened, xyz, being a Zen master, you are not going to do as well if your target is simply, I'm going to put the effort into and practice mindfulness on some kind of a semi regular basis.

[B]

And then I think a simpler way of putting that is that with mindfulness, no one who does it to get better will ever get better because what they're getting better from is the someone who wants to get better.

[A]

I don't know if they won't get better, but they will certainly, you know, downgrade their experience and the benefit.

[B]

No, I just, I just bring in the paradox in that. The.

[A]

No, it's an important paradox.

[B]

The person who, or thing that wants to be enlightened, that wants to, to, to get better, that's, that's what we're trying to observe in some sense. So that when you, when you do it with a particular goal in mind, you, you subvert the purpose in some sense. Like you, you mentioned in terms of just the, the, the three aspects of mindfulness. Deliberate attention to the present moment without judgment. If you have a particular goal, that's a sense of judgment. So that's not part of the process.

[A]

So you know, if we are going to sell this thing as a medical treatment, mindfulness practice, I think it makes sense to at least talk about some indications, kind of like FDA indications. If you were on the FDA board and you were going to approve some disorders for which mindfulness is indicated, which ones might you pick personally? And I don't think there are any real right or wrong answers. This is really just personal clinical opinion.

[B]

Let me, Okay, I guess I'll go through each one and then kind of just give my thoughts off the cuff. Number one, generalized anxiety disorder. So to me, the ruminative loops, the anxiety, the stress about the future, the worries about the past, it's part and parcel of the problems that mindfulness is trying to. Essentially mindfulness is taking a step back from those things and looking at those things rather than getting sucked into them. So to me, generalized anxiety disorder, I give it grade A in regards to recommendation for mindfulness. I think, I think this is almost like you're a requirement for teaching for patients with generalized anxiety disorder. Next major depressive disorder. Similarly, I would be, I give it an A minus. I think it's something that I think is really important especially so part of major depression is, is having those negative ruminative loops, a lot of negative self ideas, especially during depression. I also, the reason why I give it an A minus is because it's important to acknowledge that when patients are in a depressive episode, mindfulness on its own is not the only like yeah, patients can use mindfulness as a way of guilt and self blame for why they're depressed. So I'm cautious with not selling it as this will cure your depression. I use it as this is a tool to prevent slipping into depressive episodes. Whereas generalized anxiety disorder. I think it's a standalone treatment.

[A]

Yeah, yeah, I totally agree.

[B]

Moving on, let's go to ptsd. So ptsd, I'm going to give it an asterisk because mindfulness on its own can actually be, can be harmful to the patient. So it really depends on the particular patient. So because patients with PTSD are reliving their experiences, they're very traumatic. I focus more on grounding techniques than rather than mindfulness proper because mindfulness can become a very stressful thing when the world you're living in is full of threats and danger.

[A]

Yeah. If I may add to that for a moment. So far completely agree. This is the same list out I have though for generalized anxiety I'd pretty much make it the full primary anxiety chapter. But this gets confusing because I think a lot of even good clinicians are going to maybe sometimes label something with the primary organizer of anxiety chapter, DSM disorder, when there's probably multiple things going on. Right. But yes, anxiety, number one, depression, pretty helpful, but needs biological treatment. I think the general thing that we have to say here is that mindfulness is usually not standalone treatment. It is a major component of treatment in some conditions. But you need to be multimodal and personalized to the patient's case. And for what you say about grounding, I actually consider grounding techniques to be mindfulness practice. There's a broad range as we're going to get into, of what you might consider mindfulness practice. But yeah, I would say that for trauma disorders, what you might call complex trauma and cluster B personality, we should be prescribing mindfulness, but it must be a modified mindfulness. And you may need to do things that are basically more grounding techniques or they're going to be different types of mindfulness. Simple traditional sitting or counting meditation may be contraindicated in patients who have a tendency for dysregulation for any reason. You may need to be more active with the mindfulness. You may need to be more specific. You want to change which techniques are being used?

[B]

Absolutely. Should I keep going with the other conditions?

[A]

If you have any other major ones in mind that you want to suggest it for?

[B]

Well, I guess what I'll say is, I think kind of jumping off what you said. I think of mindfulness as something similar to exercise. So I think it's something that's helpful in absolutely every single patient's life. So when I say, however, when we say if it's indicated for a condition like bipolar, mindfulness is not going to treat mania, it's not going to treat a bipolar depression. That said, it's still very something worth teaching to someone who has bipolar or who has schizophrenia. However, I don't think of mindfulness as something that is helpful for the condition proper for bipolar or schizophrenia.

[A]

Yeah, that's a really good parallel. It's like exercise. It's for everyone, but it's for everyone in a different way. Right. When I say every depressed patient gets a recommendation for exercise, it doesn't mean I want every depressed patient to be running a marathon and six months. Right. That's not what that means. It means that for some patients it does mean getting back to their running routine that they had last year. But for most patients it may mean one 5 minute walk once a week or maybe even once a month. Right. You need to find a goal and something that is feasible and sustainable for each individual patient or maybe the patient's even wheelchair balance going to be upper arm exercises or going to physical therapy, who knows?

[B]

Our next condition in terms of grading is substance use disorder. And I'm going to give it an A there. I think especially you see in a lot of the AA programs, mindfulness is a huge part of treatment for substance use disorder. And a lot of it is that de Identification, the cognitive diffusion, I think in the CBT terms, essentially having a little bit of space from your thoughts so that when you have thoughts of I want to drink, I want to take a line of cocaine, whatever. The addiction is the ability to have some space and observe those things from a different perspective rather than the absolute truth. And I think for a lot of people, addiction and substance use is a way of escaping the present moment. And mindfulness in some sense is an antidote to being able to be in the present moment without the suffering that requires a numbing agent.

[A]

Yeah, I really like that conceptualization I have to admit that in my mind I didn't even think of substance use disorders because to me, I essentially lumped them in the same category as cluster B. Personally, I've never really seen addiction without at least cluster B traits, but I know that might be a little controversial.

[B]

So that's super controversial. Just for new listeners, Dr. Fu doesn't have the typical negative associations with cluster B that a lot of providers do.

[A]

Yeah, it kind of colors things. It's that I have a lot of sympathy and I think it's a legitimate condition that we need to recognize and treat. Whereas I think many people avoid doing it because of negative feelings they have.

[B]

Yeah, because I think unfortunately people will hear that you said I grew up with cluster B to B, that people who use substances are jerks. And we don't think that that's what cluster B is. And that's not. Yeah, so that's an important, important caveat.

[A]

Well then I'm going to revise and just say I've never met somebody with substance use disorder that didn't have some kind of complex trauma.

[B]

There we go.

[A]

Perfect.

[B]

Okay, I think we can move on.

[A]

Right. Is there any other major ones that we're missing? I think that's kind of of the major categories where it would be really indicated.

[B]

Yeah, I think we covered most of the things.

[A]

Well, I guess maybe it's worth saying I do agree with DBT in that targeted, scheduled and regular specific mindfulness practice, again titrated and geared towards the individual patient, is definitely a core component of the long term treatment of DSM defined borderline personality disorder. And that if you have a patient, even with strong traits and you're not teaching the mindfulness and encouraging it, you're kind of robbing them of clinical improvement. So that's a stance that I'll take anyway.

[B]

Absolutely agree. And complex PTSD I think is also grouped in the same as there. Why don't we talk a little bit about how to teach mindfulness skills? You know, because I think it's one of those things. We all agree mindfulness is wonderful, but a lot of providers aren't that good at teaching it. Either they're too esoteric in with regards to how they teach it, or they just don't know how to. So talk to me a little bit about how you teach mindfulness.

[A]

I guess the main thing that I want to start with is actually a warning and it connects actually to the personality and trauma group of pathologies. What should mindfulness not be? It should not be unpleasant. Okay. It should not be an unpleasant experience. It should not be significantly effortful. It should not be a struggle of some kind. Okay. So patients should not persist in any mindfulness practice that produces distress, dysregulation, or requires some kind of a significant effort other than commitment and time on their part. Okay. If you go into the DBT skills workbook or original manual, you will see a huge variety of different practices, both more passive and active, that are categorized under mindfulness. If you go into mindfulness manuals and workbooks beyond that, and act mindfulness. Sorry, act workbooks and manuals, you're going to find tons of different mindfulness practices. There's a traditional Indian manual that talks about a hundred ways towards enlightenment. There are so many different possible mindfulness practices. They should not be dysregulating, painful or particularly effortful beyond time commitment and just actually doing it. So please keep that in mind. Don't, don't just thrust someone into this. It's contraindicated if they're basically suffering while they're trying to practice.

[B]

Totally agree. I also want to give a caveat to the caveat that also just enjoying things is not mindfulness. Because I saw that a lot of just like people think mindfulness is. Yeah, having a good cup of coffee

[A]

if you're relaxed or enjoying yourself, that's not a bad thing. It's just more of a side effect to the problem process. That's something to keep in mind. Another word of warning I like to give. I really recommend against utilizing new media as a means to practice mindfulness in the long term. Nothing wrong with using a YouTube video or a, you know, app that has mindfulness practices at the beginning to get a flavor of things. But ideally you should be practicing mindfulness in a way that does not depend on, depend on a particular setting or external source. Right. This is something that you should be capable, you are capable of doing on your own in almost any situation. Right. If the more you limit the context and the more you rely on an external factor, the less useful the mindfulness practice will be.

[B]

So why don't we use this as a. Let's talk about how you think about teaching mindfulness. So we've talked about the warnings and not rely on particular things. So how do you teach patients to practice it in their day to day life?

[A]

It might not surprise you. You've already heard it. I think that you should plainly explain these things to the patient that you're trying to teach mindfulness thing. Mindfulness too. Everything that you've heard so far, people should get A general idea of what it is, hear about the perils and pitfalls, hear about why it's going to be helpful, in what ways it might not be helpful, and what the goals are. So essentially what we covered, but shorter. I wouldn't get too stuck into that part, though, because there's one thing to explain a concept and there's another thing to actually practice it. So when it comes to practicing it, I've tried many different things over the years. But these days, to be honest with you, I pretty much just give them the mindfulness handouts from the DBT manual. And this is, again, not limited to patients who have a diagnosable personality condition or cluster B traits. I just think it's a very good handout.

[B]

Yeah. So it's actually a pretty big. If you just go through the whole mindfulness chapter. There's a lot there. Maybe. Why don't we do a. Should we try to do a role play with regards to how you would talk to a patient? I know we've. We've talked about it before, but I always find that that's the most helpful. So would you be open to that?

[A]

I feel like it would cover too much. Let's just jump into I've already explained everything, and then we'll do some role play. Okay. How about that? I've already done the psychoeducation component. Okay. So, you know, for your condition, I think this is a practice that's really going to help you. The medications might help you so somewhat, but I think this is really going to help you in the long run in terms of getting better. I've sent you this handout. I don't think you have a personality disorder, by the way, but DBT for Borderline Personality Disorder just happens to have really great set of mindfulness skills in one handout that you can kind of pick and choose from. How do you feel about trying these out before the next time we meet?

[B]

My only concern. I've tried meditating. It's just not for me.

[A]

Yeah. Now, keep in mind, I don't want you to do anything that you feel like isn't working for you in long run. And this isn't just about meditation. I'm not asking you to be sitting in place or anything like that. There are a lot of different ways you can do this. You can be active about it. You can not be active about it. All I need is something like five minutes once a week. What do you think?

[B]

So when you say five minutes once a week, it's kind of what you were saying. Before of just kind of being in the present moment and not being judgmental, just like randomly throughout the day, just a random five minutes.

[A]

I wouldn't do it randomly. I actually think that can be a little challenging, at least to start. All I want is for us to commit to one time a week where you're not going to be busy, overly distracted, or likely to be too upset, because this is not something that you should be doing when you're totally upset. Okay. If you're above like a 7 or 8 out of 10 in distress, there are different skills for that. This is going to be something kind of like upkeep or exercise, you know? So can you pick a time once a week, just for five minutes to start, where you can just try out some of these exercises?

[B]

Yeah. So, okay, so I'll pick a random five minutes. And when you say some of these exercises, I'm looking through the packet you sent. There's just like, it's huge. And there's a ton of different things it recommends. Which one do you. Would you pick for me?

[A]

Well, you know, it sort of depends on your experiences that you've had before. If you've never tried anything before, I would just start with the sitting and counting or naming things around you. That's something that you can do. But as you can see, there's also not just those options, but there's even some participate mindfulness skills that you see in the package. And to start with, I would just pick any of them and try them out once. See which ones work the best for you. The point is, again, just to pay attention to the here and now without judgment. And remember, if you find yourself struggling with that and you judge yourself for it, don't worry about it. Judging yourself for judging yourself is a type of judgment too. Just notice that you're doing it and try to put your attention back on whatever it is that you're trying to pay attention to. That's all you have to do. And after about five minutes or even less, if you feel like it's a problem, just stop and go about the rest of your week. Just try a few out, you know, maybe two or three of them in the next four weeks, and then we'll meet again next time.

[B]

Awesome. Anything else you want to end before we wrap up the roleplay?

[A]

Not exactly. Here's the thing, if you try to make it too regimented, make it too official, I think that's going to raise the likelihood that it's not going to work well. So my recommendation is to be extremely casual about this, but don't let it be haphazard because if you don't explicitly schedule it and tell people to not use it as a escape or distress management tool, they will do that because, frankly, at least the first time or the first few times, it works pretty well. Grounding techniques and mindfulness to escape panic or distress. Okay. It will stop working pretty quickly like any PRN if it's used that way. Instead, we want to get people used to practicing it when they don't, quote, unquote, need it. Right. And that's the purpose of me picking a very specific and short time frame and having them try out different practices. Perfect.

[B]

Yeah. And one thing I like to, when I talk to patients about this, in regards to what you're kind of just saying, I said, like, have you ever heard the phrase strike when the iron's cold? And then if they heard of it, essentially I'm saying that the goal of this isn't, is to practice when things are calm and easy so that it helps during the more stressful periods. If you only practice during the stressful periods, you're going to be too ramped up to really kind of get the benefits or see it work. So I recommend working on these things not during, during times of great stress and as a goal to calm things down.

[A]

Yeah. Not something I explain to the patients, but among us clinicians, the general theory here is that we are trying not to associate the practice psychologically, consciously or unconsciously with distress. If you need to teach distress tolerance skills, the DBT tip skills are great and you can pick other ones. If you're a fan of prescribing PRNs. I am not. You can probably do that too. But we're trying to disengage the distress mindset from this practice fundamentally. And if you don't get in front of that, I think most people rationally will put those two and two together. So, you know, make sure those two are separate things.

[B]

Now, as we're talking about teaching mindfulness, I want to give a practical tip for people, for new practitioners or people who aren't quite comfortable teaching it just based off of what we've heard. One thing that I do that I did early on in residency when I wasn't as confident with this material, I search DBT mindfulness PDF. Let me make sure that this is actually true.

[A]

There is a Kaiser doctor who has uploaded onto the patient portal the first the DBT handouts from the Mindfulness module, the most important module of dbt. And that's still the one I direct patients towards so I don't have to share copyrighted material. Sorry to that Kaiser doctor. Hopefully it doesn't disappear from Google and

[B]

because I don't have it bookmarked and I'm constantly in different rooms that don't have my bookmarks. If you just Google DBT Mindfulness PDF, the first thing that comes up is Kaiser Permanente. Click that one. Then what I do usually is I share my screen and then we walk through the particular handouts that I want to walk through. So in terms of just the basics of what mindfulness is, I would literally just read with the Patient Mindfulness Handout 1A which asks the question what is mindfulness? What are mindfulness skills and what is the practice? And then as I've gotten more and more comfortable, I'll tailor which things I want to pick for which patients. In regards to what's helpful, I also really like I think an important one is mindfulness Handout four the what skills Observe, describe, participate. I find those ones really helpful for quickly getting patients into the mindfulness headspace. So there it really just goes through the three what skills of mindfulness which are Observe, describe, participate. For observe, you're just noticing the body sensations. Same principles as what we were saying before. Paying attention to the present moment without judgment. And then you're just supposed to practice wordless watching and observe the inside and outside of everything that's kind of going on. Describe is you put words to your experience and label what you observe, usually without loaded value based judgments. So you're not trying to say like I'm having a bad headache. You can say there's a pressure in my head, the tingling is on the left side. You're just trying to describe without judgment the things that are occurring. Participate I think of as like the flow state. So you are trying to throw yourself into whatever you're participating in or acting in without thoughts of being angry at yourself or judging yourself and becoming one with what you're doing. Going with the flow.

[A]

I like to observe and participate ones the most. Go on.

[B]

Yeah, I like observe and describe the most. Participate I think is tough as a skill for people to practice. Whereas I find observe and describe even in my own life. Actually I have a great example. A few days ago I Woke up at 4am and I couldn't fall back asleep and I was having all these thoughts of like oh God, I'm screwed for tomorrow. And then I decided to practice the describe skills. This is actually a true story because me and my wife just made the video for the what skills you can watch on our channel. And I just described it's 4am, I've been sleeping for six hours and it actually worked really well. It helped me calm down, which is not the purpose of it, but it did work.

[A]

I do feel that DSCRYB is a little riskier when it comes to ruminators, but again, it's very individual, which is why I just buffet it. I really say, look, these are listed in general and in detail in all these handouts. You look at 4a, 4b, 4c. There's so many different ideas that you can try. You just got to find what works for you. I also want people to get an idea of the wise mind on handout three, especially if they actually are more borderline spectrum. So, you know, to me, the introduction may be important, but maybe just as important or maybe more important is follow up. Because not everyone's going to actually do this after you've set that goal together. Right. And this is where your CBT training really kicks in. You should follow up with the patient's experience of the mindfulness, what it was like for them when they tried or what happened that caused them not to try, even if they remembered. Or did they not schedule at all? Do they keep a calendar at all? All the basic CBT homework stuff that you might have learned or can learn. And if somebody tells you that they did try it, I think it's very important for you to take a neutral and inquisitive stance to get their genuine experience of it right. We want to review with the patient and make sure that there isn't some kind of a false sense that they had to have enjoyed it or felt that it was beneficial. Beneficial Instead of stupid or waste of time, you want to process those emotions and reorient towards the major purpose of the mindfulness practice, which is long term change. Just like the way we counsel patients on that. You know, this SSRI is not supposed to make you feel happy right away. You know, this is something that's going to make it easier for you to change and improve over the course of months if you stick to it. We should be saying the same thing about mindfulness. People can and do get immediate benefits, but that's sort of like the little bit of sedation on buspirone. It's not the main treatment effect.

[B]

Yeah. And I think an important part of checking in is also I find, especially with any sort of recommendation I make, I always like before I check in on it, I always go like. And by the way, often most patients don't follow up my recommendation. So no worries at all if, if, if you weren't able to get to it. Because a lot of times when patients are defensive and scared that they feel like the appointments are homework, you can. First off, you can lose patients that way because they just feel a pressure to do things and they're avoidant. And so I just said always preface these things with a disclaimer that it's okay if they miss it. And that's part of the process.

[A]

Yeah. This took longer than expected to explain all these things. I had some original sense that maybe I'd touch on briefly some other important ideas from the Buddhist tradition, but I don't know if that would be a turn off for people.

[B]

You always love teasing us with the part two.

[A]

It's definitely not enough for a part two. I think I can cover it in two minutes.

[B]

Well, I think we're going to have to wrap up here because. Because we don't want to belabor and have a two hour long mindfulness episode.

[A]

Okay. I suppose it can be fit in into some kind of a miscellaneous, you tell me type episode for which we may be overdue.

[B]

Well, do you have a short, pithy thing to teach us before we head off the call?

[A]

Sure, sure. I think we just don't recognize necessarily that there are traditional ideas that kind of are the best ideas that live in every corner culture's use of medicine. And two ones I want to highlight that you can probably see evidence throughout this episode is the concept of skillful needs. Right. And Buddhism, there's a concept of that to bring people to improvement, enlightenment, whatever you want to call it essentially has to be personalized. Okay. It doesn't. Don't get too stuck on the details. You have to pick a strategy that's going to work well for the person that you're working with or that the person that you are that skillful means. In a nutshell. The other one isn't exactly Buddhist. I think it's from traditional Indian medicine. But it's basically the idea of right diagnosis, right treatment. You're not going to be able to get to a right treatment unless you have the right diagnosis or formulation. And that's sort of maybe one of the major underlying features of my philosophy as a treater and in many of these episodes. I don't know if it's exactly Buddhist, but I thought I'd just mention it. There are many other great lessons, I think philosophically from mindfulness, traditions and other traditional cultural things, but we're at it.

[B]

Oh, I would love to hear a full episode of this, but I won't make you do it.

[A]

I don't think people do. All right, well, I'll see you next time.

[B]

Have a good one. Thanks for listening. If you want to support the show, check out my very practical antidepressant course. If you want to check that out, go to Psycho Pharm Sleep. If you prefer to read, you can go to Amazon.com you can just search my name Gregory G R E G O R Y Malzberg M A L Z B E R G and the book is Psychopharm's Guide to Treating Depression. It's a nice, easy, readable, practical guide to medications for depression.