Clin Soc Work J (2014) 42:218227

DOI 10.1007/s10615-014-0476-3

ORIGINAL PAPER

The Clinician as Neuroarchitect: The Importance of Mindfulness

and Presence in Clinical Practice
Lisa L. Baldini Suzanne C. Parker
Benjamin W. Nelson Daniel J. Siegel

Published online: 28 January 2014

 Springer Science+Business Media New York 2014

Abstract Interpersonal neurobiology provides a frame- Keywords Interpersonal neurobiology
Mindsight

work from which to examine the incorporation of mind-
sight and mindfulness into clinical practice, employing the
brains capacity for neuroplasticity to move oneself and
ones clients toward greater well-being. Through the lens
of interpersonal neurobiology, this article will examine the
benefits of mindfulness for clinicians, clients, and the
therapeutic relationship. Lasting changes associated with
mindfulness practices, including the hypothesized potential
to alter ones previously insecure attachment patterns, will
also be discussed. An explanation of how to cultivate
mindfulness by starting with presence and sustaining the
practice with compassion will then be presented. Finally,
practices that cultivate growth within the therapistclient
relationship will be explained, along with clinical appli-
cations and recent research demonstrating the neural cor-
relates of these practices and how they are effective at the
level of the brain itself.
Mindfulness
Presence
The past decade of neuroscience research shows that the
human brain is in a constant state of change, with new
experiences continually reshaping neural circuitry and
impacting emotions, cognitions, and behavior (Davidson
and Begley 2012). Using the principles of neuroplasticity
in clinical practice enhances the therapistclient relation-
ship, and harnesses specific neural changes that can occur
with intentional interaction. By promoting neural integra-
tionthe linkage of differentiated parts of a systemthe
clinician can facilitate growth in a client (Siegel 2010a).
Clinicians can therefore be seen as neuroarchitects,
sculpting the flow of energy and information, both within
themselves and between others, to rewire the brain toward
a state of integration (Parker et al., in press). To help the
client move toward integration, the therapist as a neu-
roarchitect must have a stable, flexible, and adaptive inner

L. L. Baldini (&) D. J. Siegel

Center for Health Care Evaluation, VA Palo Alto Health Care
System, 795 Willow Road (152-MPD), Menlo Park, CA, USA
e-mail: LisaLBaldini@gmail.com
S. C. Parker
University of Miami, Coral Gables, FL, USA
B. W. Nelson
UCLA Semel Institute for Neuroscience and Human Behavior,
Los Angeles, CA, USA
UCLA School of Medicine, Los Angeles, CA, USA
D. J. Siegel
UCLA Mindful Awareness Research Center, Los Angeles, CA,
USA
D. J. Siegel
Foundation for Psychocultural Research-UCLA Center for
Culture, Brain, and Development, Los Angeles, CA, USA

B. W. Nelson
Department of Psychology, University of Oregon, Eugene, OR,
USA

D. J. Siegel
Mindsight Institute, Los Angeles, CA, USA

123
Clin Soc Work J (2014) 42:218227
world to be able to hear, process, and reflect back the cli-
ents experience coherently (Siegel 2010a).
Interpersonal neurobiology provides a framework from
which to examine the incorporation of mindsight and
mindfulness into clinical practice, employing the brains
capacity for neuroplasticity within the therapistclient
relationship. Interpersonal neurobiology, an interdisciplin-
ary approach that integrates a broad range of sciences,
proposes that the mind is an emergent property an
embodied and relational process that regulates the flow of
energy and information (Siegel 2012b, p. 2). The
embodied aspect of the mind involves basic neural pro-
cesses and subjective experience, while the relational
aspect includes the processes and experiences that arise
from interaction with other people. Mindsight refers to the
ability to sense and intentionally shape the minds energy
and information flow, both in oneself and in relationships.
It incorporates elements such as present moment awareness
that are the backbone of mindfulness (Siegel 2010b).
Through the lens of interpersonal neurobiology, this
article will explore the benefits of mindfulness for clini-
cians, clients, and the therapeutic relationship. Lasting
changes associated with mindfulness practices, including
the hypothesized potential to alter ones previously inse-
cure attachment patterns, will also be discussed by exam-
ining the convergent findings of secure attachment
outcomes, mindfulness outcomes, and functions of the
medial prefrontal cortex. An explanation of how to culti-
vate mindfulness by starting with presence and sustaining
the practice with compassion will then be presented.
Finally, practices that cultivate growth within the thera-
pistclient relationship will be explained, along with clin-
ical applications and recent research demonstrating the
neural correlates of these practices and how they are
effective at the level of the brain itself.
Interpersonal Neurobiology
From the perspective of interpersonal neurobiology, the
embodied brain is seen as the mechanism through which
energy and information flow within us. This embodied
brain, henceforth referred to simply as the brain, is a
complex system that integrates the nervous, gastrointesti-
nal, immune, vascular, and endocrine systems within the
body (Siegel 2012a). The brain is part of a complex system
that has four important qualities critical to its functioning.
First, it is dynamic; functionally and structurally in an
ongoing state of change. The brain is also open; it interacts
with and is affected by environmental influences. The brain
is also nonlinear; seemingly minor inputs have the ability
to cause large and unpredictable changes in the whole
systems performance. Finally, because it is also capable of
219
entering chaotic states, the brain can be considered a
complex system. Complex systems like this have emergent
propertiesprocesses that arise from the interaction of the
systems elements (Siegel 2012b).
Human beings can be considered to be both embodied
and socially embedded complex systems that have a par-
ticular emergent process called self-organization. Self-
organization refers to the process that arises from the
system itself and from self-other interactions. It regulates
energy and information flow within and between us. This
self-organizational process is a central aspect in the term
mind, which also includes subjective experiences and
consciousness (Siegel 2010a, 2012a). Because the mind is
self-organizing, it is fundamentally important to incorpo-
rate the interconnectedness and relational aspects of this
complex system into clinical work. By examining the
properties of self-organization, clinicians gain practical and
powerful insights into how to help identify an unhealthy
mind and help that mind move toward well-being. At the
heart of this approach is the idea that optimal self-organi-
zation moves the system toward flexibility, adaptability,
and stability. When linkage or differentiation does not
occur, the system moves toward chaos (uncontrolled dif-
ferentiation), or rigidity (limiting, over-linkage), or some
combination of both (Siegel 2007).
Attunement, Mindsight, and the Resonance Circuit
In interpersonal neurobiology, the mind is viewed not
simply as the output of the brain. Rather, the mind is an
emergent, self-organizing process that arises from and
recursively regulates the flow of energy and information in
the complex system that exists within the individual and
between the individual and others (Siegel 2012b). The
embodied flow of energy and information occurs within the
brain, whereas relationships are seen as the sharing of
energy and information (Siegel 2009, 2012a, b). The mind
thus both grows from and regulates the relational process.
Though it arises from the activity and information flow of
the brain, it also encompasses shared interpersonal
exchange between parties. Many things can facilitate this
exchange of energy and information during interaction,
including verbal communication, nonverbal exchanges,
posture, and eye gaze. Hasson et al. (2012) call this
exchange during the relational process brain-to-brain
coupling. They describe how witnessing the actions,
sensations or emotions of another person prompts similar
cortical representations in the witness (p. 115). In this way,
the neural activations and responses of each party become
linked as one brain directly affects the neuronal circuits and
corresponding states of another brain.
Mindsight encompasses this ability to discern and shape
energy and information flow both within oneself and in
123
220
relationships. It allows for integrative communication
between parties that honors differences and cultivates
compassionate connections (Siegel 2010b). Mindsight
allows one to regulate both intrapersonal and interpersonal
experience by monitoring and modifying the flow of energy
and information within ones own nervous system and that
of another. In the therapistclient relationship, having this
ability allows a therapist to accurately perceive the state of
the client, and allows clients to be in touch with and
transform their own internal processes (Siegel 2010a, b).
The neural mechanisms that are thought to enable both
mindsight and the interpersonal benefits of mindfulness can
be thought of as a resonance circuit (Siegel 2007). These
functional connections in the resonance circuit communi-
cate the intentions of another, generating a flow of neural
firing downward through the insula to create shifts in the
limbic region, brainstem, and body that produce a physi-
ological representation of anothers intention. Many inter-
personal functions supported by the resonance circuit may
also be amplified by mindfulness, as many pre-frontal
capacities have been linked with practices of mindfulness
and secure attachment (Siegel 2007, 2012a). The resonance
circuit can thus be thought of as a neural hub for supporting
interpersonal attunement (Siegel 2007).
A major component of the resonance circuit is the
mirror neuron system, which provides a connection
between action and perception, and fosters attunement with
another person. Studies by neurologist Marco Iacoboni
(2007, 2009) have demonstrated that the mirror neuron
system links the occipital, temporal, and parietal cortices,
which sense and observe the external world, to motor areas
in the frontal lobe that mediate behavioral action. This
creates a neural coupling between the two parties (Siegel
2010a). Carr et al. (2003) suggest that the mirror neuron
system is closely engaged in emotional processes, mediated
through the insula. Here, the insula serves as a circuit
transferring information from the cortex to alter lower sub-
cortical areas, including the limbic regions, brainstem, and
body proper. Information is then relayed upwards via the
vagus nerve and lamina I, the most prominent intero-
ceptive pathways (Damasio and Carvalho 2013, p. 146),
which carry an array of bodily information to the brain-
stem, insula, and subsequently to the prefrontal cortex.
Because prefrontal feedback regarding interior subcortical
and bodily states has a direct impact on how one perceives
another persons feelings, it serves as a gateway to emo-
tional understanding and attunement. Finally, elements of
the resonance circuit (the insula, anterior cingulate, and
medial prefrontal cortex) facilitate this flow, which creates
interoception, an attunement to the interior physiological
condition of the body and subsequent emotional responses
(Craig 2003, 2008). Thus, in the therapeutic relationship,
the therapists mirror neuron system can attune to the
123
Clin Soc Work J (2014) 42:218227
clients brain through this route, allowing the therapist to
internally approximate the clients neuronal, physiological,
and emotional processes (Nelson et al. 2013).
In this way, the resonance circuit enables people to have
the sense of feeling felt through the blending of intra-
and interpersonal attunement (Siegel 2007). Feeling felt,
or experiencing anothers attunement to ones own internal
state repeatedly over time, helps develop the capacity for
affect regulation, especially in therapistclient and parent
child relationships (Feldman 2007). The learned quality
of this regulation comes from the integration of different
regions of the brain. In other words feeling felt balances
and synchronizes the nervous system, which allows dif-
ferentiated regions to become linked through integration
(Siegel 2007). Integrative relationships involve attuned
communication among people; integration in the brain,
such as aspects of the middle prefrontal cortex, involves
linkage of separate neural areas and their specialized
functions. In this way, clinical work that is informed by
mindsight and reflective mindfulness practices may likely
build integrative connections in the brain that promote
emotional well-being (Siegel 2010a). Through under-
standing that integration in the brain is the basis for self-
regulation, the link between therapeutic relationships and
the development of these important regulatory processes
that support well-being becomes more apparent.
Benefits of Mindfulness for the Clinician, Client,
and Therapeutic Relationship
The Importance of Mindfulness for Clinicians
With this understanding of interpersonal neurobiology,
clinicians can begin to explore the benefits of integrating
presence and mindfulness into their personal and profes-
sional lives. Although it may seem counterintuitive, one of
the most important elements to help clients heal is to start
by healing oneself, the clinician. This approach parallels
the attachment research showing that the best predictor of a
childs attachment to a parent is the parents own self-
understanding (Siegel 2012a). Due to the many occupa-
tional hazards for healthcare professionals, such as higher
rates of burnout, anxiety, depression, substance use disor-
ders, and even suicide, it is essential for clinicians to take
the necessary time for self-care (Irving et al. 2009;
Shanafelt et al. 2012). Research shows many benefits of
mindfulness interventions for healthcare professionals,
including reduced burnout, improved mental health and
well-being, and enhanced therapeutic relationships (Irving
et al. 2009; Shanafelt et al. 2012; Shapiro et al. 2005).
Together, these changes can make therapists more resilient
and effective in clinical practice.
Clin Soc Work J (2014) 42:218227
Burnout and clinician well-being have received
increasing attention in recent years (Goodman and Schor-
ling 2012). Several medical centers have found that
mindfulness training for healthcare professionals signifi-
cantly reduces burnout, with some improvements lasting up
to 15 months (Goodman and Schorling 2012; Krasner et al.
2009). Additionally, mindfulness training, such as mind-
fulness-based stress reduction, has been linked to improved
mental health symptoms among therapists. These include
decreases in stress, negative affect, rumination, and anxiety
(Shapiro et al. 2007). Further restorative benefits of
mindfulness training include increased positive affect, self-
compassion, life satisfaction, and immune functioning
(Irving et al. 2009; Shapiro et al. 2005, 2007). Mindfulness
training has even been found to increase levels of the
enzyme that maintains and repairs the ends of human
chromosomes, which can shorten with age and stress
(Jacobs et al. 2011).
Mindfulness training for therapists can also enhance the
therapeutic relationship (Christopher et al. 2011). Research
has found that therapists who practice mindfulness are
better able to pause before reacting, accept their emotions,
and have increased awareness of patients non-verbal
signals (Christopher et al. 2011). Several studies have also
demonstrated that mindfulness practices significantly
increase empathy among therapists and other healthcare
providers (Krasner et al. 2009; Shapiro et al. 1998). A
study by Grepmair et al. (2007) compared the therapeutic
relationship and clinical outcomes of clinicians who
received mindfulness training to those who did not.
Therapists trained in mindfulness practices received sig-
nificantly higher client ratings of their therapeutic rela-
tionship, ability to problem-solve, and ability to
communicate skillfully. Interestingly, clients of these
therapists also reported a greater reduction in symptoms
than the control group.
Benefits of Mindfulness Regarding Attachment Patterns
Due to the lifelong opportunities for neural change made
possible by neuroplasticity, sub-optimal childhoods are not
a life sentence. Using mindfulness practices can provide
many benefits for both client and clinician, including some
that are hypothesized to help change deeply entrenched
attachment patterns. Attachment researchers, including
Mary Ainsworth, John Bowlby, Mary Main, and Alan
Sroufe, have distinguished four attachment patterns based
on the interactions of mothers and infants: secure, avoidant,
ambivalent, and disorganized (Cassidy and Shaver 2008).
These patterns are now being further understood through
the lens of modern neuroscience, specifically using the
principles of neuroplasticity. As Parker et al. (in press)
explain, the therapist acts as a neuroarchitect who
221
provides a way to rewire the brain toward integration.
The therapist as a neuroarchitect must have a resilient and
flexible inner world in order to listen and frame back the
clients experience in a coherent manner that encourages
the client to move towards integration.
The extensive literature on attachment patterns reveals
their immense importance both clinically and in daily life.
Sroufe and Siegel (2011) explain the long-term impact of
attachment on future functioning, stating, In general,
attachment predicted engagement in the preschool peer
group, the capacity for close friendships in middle school,
the ability to coordinate friendships and group functioning
in adolescence, and the capacity to form trusting, non-
hostile romantic relationships in adulthood (p. 4). Thus,
the interpersonal experiences within the dyadic relationship
of mother and infant have a lasting impact on the devel-
oping infant.
Interestingly, while these early experiences have a major
impact on brain development, relationships throughout the
life continue to influence ones attachment status. Siegel
and Hartzell (2003) discuss how the ability to form a
coherent narrative of ones childhood in the face of chal-
lenging childhood experiences can lead to a subset of
secure attachment termed earned secure attachment, which
can occur for a client with his or her therapist. Addition-
ally, healthy attuned relationships with others later in life,
including romantic and friendship, can also lead to earned
secure attachment.
Because humans carry models of attachment from their
pasts within the brain, these models can transform with
attuned experiences. Essentially, ones attachment status,
encoded in the limbic system, is capable of neuroplastic
change, as demonstrated by research illustrating how
experiences such as mindfulness practice change brain
structure and function (Davidson and Begley 2012). Mul-
tiple researchers have demonstrated an overlap between a
variety of mindfulness and secure adult attachment out-
comes (DiNoble 2009; Goodall et al. 2012; Mikulincer and
Shaver 2007; Ryan et al. 2007). From this work, one could
hypothesize that as mindfulness enhances these shared
characteristics, it may also have a beneficial effect on ones
own attachment status (Siegel 2007).
In-depth exploration of the outcomes of these two usu-
ally independent fields reveals many similarities between
mindfulness and secure attachment (Kabat-Zinn 2003;
Siegel 2007; Sroufe et al. 2005). Interestingly, both are
associated with functions of the middle areas of the pre-
frontal cortex, which has the capacity to change throughout
adulthood. Their proposed common mechanism is attune-
ment: internal attunement for mindful awareness, and
interpersonal attunement for secure attachment (Siegel
2007). Thus, as therapists and clients develop mindful
awareness practices, it can potentially help rewire the same
123
222
brain structures necessary for earned secure attachment
(Siegel 2007).
Cultivating Mindfulness: Start with Presence
and Sustain with Compassion
Presence: The First Step
A good place to begin cultivating mindfulness is to develop
the faculty of presence. Presence is an essential component
of mindfulness and consists of attending fully to each
moment without being swept up by thoughts about the past
or anticipation of the future. It unites bare attention,
direct experience of here-and-now sensory information
with little filtering by top-down processes acquired from
prior events, with the receptive and flexible quality of
being aware of and open to what one is experiencing
(Parker et al., in press). Presence and mindfulness differ in
that mindfulness involves not only presence, but also an
observing meta-awareness of ones experience that is both
nonjudgmental and also aware of this awareness (Parker
et al., in press).
In the therapeutic relationship, presence is profoundly
helpful, and can be seen as the most important element in
helping others heal (Siegel 2010a, p. 2). Being present
with a client means being open and receptive toward
everything the client shares. It helps therapists to better
notice their own urges to Do something! or immediately
fix the situation because of their own discomfort and
judgments. If therapists are unaware of these feelings and
show this discomfort, it can teach their clients that the
therapist cannot tolerate the clients inner experiences. This
can reinforce the clients already narrow window of toler-
ance for a particular emotion and recursively embed dif-
ficulties. The window of tolerance refers to the ability to
function optimally in mental experience and neural firing
patterns in which one is neither in a state of chaos nor
rigidity (Siegel 2012a). When therapists cultivate presence,
they can better tolerate feelings of discomfort and let the
therapeutic process unfold naturally.
As therapists join with their clients and offer them a
larger interpersonal space in which emotion can be shared,
they are widening the clients window of tolerance for
difficult emotions or experiences (Siegel 2010a). In doing
so, therapists can use the same resonance circuit to practice
intrapersonal attunement (being fully aware of what they
are experiencing in the present moment) and interpersonal
attunement (resonance with the state of another person in
the moment). This resonance helps the client to feel part of
a large we that is at the heart of healing and transfor-
mation. The therapists presence, an open and receptive
state of being that is the beginning of any therapeutic
123
Clin Soc Work J (2014) 42:218227
relationship, enhances this resonance (Geller and Green-
berg 2002; Siegel 2010a). Interestingly, being present is
not only helpful, but also personally rewarding for clini-
cians. In one mindfulness intervention, physicians reported
that finding meaning in their work correlated more strongly
with being present with patients than with providing
accurate diagnoses or procedures (Dunn et al. 2007).
It is important to emphasize that the neural and physical
mechanisms of presence that support the resonance circuit
can be trained. Intra- and inter-personal attunement, which
arise in part from a sense of presence, are learnable skills
that are particularly important in clinical connection and
communication. Mindsight facilitates the resonance circuit
and the mechanisms underlying intra- and interpersonal
attunement through the ability to sense and shape that
energy and information flow. Training in presence involves
consistent intentional orientation to the nowthis very
instant. Presence is the sense of awareness that precedes
interpreting and filtering of a moment through a framework
of fixed, set patterns of prior learning (Parker et al., in
press). Training to be present in moment-to-moment
experience literally shifts brain activity from a centralized
neural circuit consisting of an observing and narrating self
to a lateral circuit associated with non-conceptual sensory
experiencesthe sensing self. This differentiation of the
sensing self from the observing self helps disengage the
mind from rumination and perseveration (Farb et al. 2007).
It also offers an alternative to traditional cognitive thera-
pies that attempt to control negative emotions and experi-
ences through suppression or reappraisal (Farb et al. 2012).
In addition to reducing destructive thought patterns,
research has indicated that presence can even lead to
greater happiness by counteracting mind wandering and
unhappy moods, which can create and reinforce each other
(Kane et al. 2007). By intentionally cultivating presence,
therapists are better able to attend to themselves, their
clients, and the therapeutic relationship.
Compassion and Mindfulness: A Synergistic
Relationship
One of the most beneficial tools to sustain and enhance
ones mindfulness practice is through compassion (Neff
2012). Mindfulness and compassion can be used as distinct
but complementary meditation practices that support and
enhance one another, and each practice includes the other
(Neff 2011, 2012). The two are so interwoven that some
argue self-compassion is a critical component of mindful-
ness-based interventions (Kuyken et al. 2010). If one does
not bring a compassionate attitude to mindfulness practice,
it can become rigid, restrictive, and counterproductive.
On the other hand, mindfulness provides compassion
practice the necessary stable awareness and a non-reactive,
Clin Soc Work J (2014) 42:218227
non-judgmental attitude, allowing things to be as they are
without over-identifying with them (Neff 2003). Addi-
tionally, while mindful acceptance focuses on accepting
thoughts, emotions, and experiences, self-compassion
focuses on accepting the person who is experiencing these
things (Germer 2009). Consequently, it can become easier
for people to relate to their feelings, thoughts, and expe-
rience with mindfulness when they feel loved and accepted
(Neff 2011).
While mindfulness meditation has received extensive
scientific exploration, investigations of the underlying
neural and psychological mechanisms of compassion
meditation are in earlier stages (Fredrickson et al. 2008;
Klimecki et al. 2013). A study by Antoine Lutz et al.
(2008) examined the effect of compassion meditation on
individuals empathetic responses. During compassion
meditation, the brain circuits involved in empathetic states
were activated when meditators were presented with
emotional sounds of humans vocalizing distress or joy.
Additionally, increased meditation experience was linked
to greater perception of these emotional sounds. These
findings demonstrate how compassion practice can enhance
empathetic response as well as how compassion can be
trained.
Similar to developing mindfulness, cultivating compas-
sion is beneficial for the therapist, the client, and their
relationship. Low levels of self-compassion have been
linked to insecure attachment patterns, coming from a
dysfunctional family, and having a critical mother. Thus,
self-compassion expert Kristen Neff explains the impor-
tance of teaching self-compassion to clients (Neff and
McGeehee 2010). She states, Given that therapy clients
often have problems related to their family backgrounds,
they may be especially likely to benefit from developing
greater self-compassion (Neff 2011). Recent research
supports this notion, with a meta-analysis of fourteen
studies revealing a strong relationship between increased
self-compassion and decreased mental health symptoms, in
particular anxiety, stress, and depression (Macbeth and
Gumley 2012).
For therapists, even brief training in compassion can
enhance resilience in the face of suffering. One study found
that after a day-long compassion training, participants had
increased positive affect and activation of the middle pre-
frontal brain region when viewing distressing images
(Klimecki et al. 2013). This suggests that compassion
training may help develop a greater sense of equanimity
amidst suffering, as opposed to becoming overwhelmed
and consequently less effective. In terms of compassions
effect on the therapeutic relationship, research has found
that the way in which therapists relate to themselves, with
compassion and warmth versus judgment and self-criti-
cism, influences how they relate to clients (Henry et al.
223
1990). Therefore, therapists who treat themselves with
more kindness will be more likely to treat their clients in
the same way. As psychologist Shauna Shapiro tells her
clinical students, Cultivate self-compassiondo it for
your future patients! (Shapiro 2013).
Clinical Applications of Mindfulness and Compassion:
Tools and Practices
Starting with presence and adding compassion to offer a
gentler, more patient approach creates a solid foundation
upon which to cultivate mindfulness. This section will offer
a few mindfulness and compassion practices for clinicians
to explore for themselves, as well as to use directly with
clients. It is important to emphasize that, while offering
these practices to clients may be the ultimate goal, the
therapists own internal commitment to practicing and
embodying mindfulness is vital. The more therapists
practice and experiment with various exercises, the easier it
will be to select the most appropriate practice for each
client based on temperament, situation, mood, and other
factors.
Selecting which practices to use with each client is a
clinical judgment. Regardless of which exercise is used,
two underlying themes that characterize all mindfulness
practices are awareness of awareness and paying
attention to ones intention (Siegel 2009). Additionally, it
is important to note that though mindfulness practices have
proven beneficial for many populations with varying con-
ditions, these practices are not appropriate for everyone.
Mindfulness interventions are often not recommended for
individuals with a history of severe trauma, dissociation,
active substance abuse, or psychosis (Santorelli and Kabat-
Zinn 2009). There are individuals with these conditions
that have benefitted from mindfulness; however extremely
careful application of mindfulness practices with these
populations is clinically advised, as they have the potential
to lead to dysregulated states (Siegel 2010b).
One critical component of mindfulness that is some-
times overlooked is cultivating awareness of ones body.
Becoming aware of ones body, known as interoception,
can help clients literally get out of their thinking heads
and into their bodies by using the direct sensory circuits of
the brain instead of the more familiar observing, narrative,
ruminating circuits (Farb et al. 2007). Practicing bodily
awareness to activate these sensory neural pathways
bypasses traditional top-down thinking, allowing the body
to actually inform a person of how he or she is feeling.
Interestingly, increased bodily awareness is linked to
greater empathy and compassion, which could be due to
the involvement of the anterior insula, a region also asso-
ciated with empathy (Gu et al. 2012; Siegel 2012a).
123
224
Particularly useful bodily awareness practices can include
the body scan meditation, walking meditation, yoga,
qigong, and tai chi. Practicing bodily awareness strength-
ens interoception, which is linked to many functions of
well-being such as self-regulation and internal attunement
(Siegel 2010a).
In addition to body-centered mindfulness practices,
another highly integrative practice is the wheel of aware-
ness (Siegel 2010a, b, 2012b). The wheel of awareness is
quite versatile and can be used with a wide range of clinical
conditions. In this exercise, a wheel is used as a metaphor
for the mind, with the center hub representing an open state
of receptive awareness. The spokes of the wheel, repre-
senting a persons focus of attention, connect the hub to the
rim, an outer region representing anything the person can
be aware of. The rim contains what is known in a per- brain region associated with fear that activates the brain-
sons consciousness. This wheel imagery allows the prac-
titioner to distinguish his or her awareness, which is
represented by the hub of the wheel, from conscious,
moment to moment awareness of specific things, which is
represented by the rim of the wheel. One mindfulness study
suggests that by focusing on a single area of the rim, such
as breathing, one can strengthen and actually thicken parts
of the middle prefrontal region of the brain (Lazar et al.
2005). This region holds many beneficial functions,
including bodily regulation, attuned communication,
emotional balance, response flexibility, empathy, insight,
fear modulation, morality, and intuition (Siegel 2007).
Focusing on one object of the rim systematically and
learning to differentiate the hub of awareness from the rim
can be particularly useful for clients. Individuals with
anxiety or attention deficit disorders may especially benefit
from this type of traditional mindfulness practice that can
help calm and focus their minds (Zylowska et al. 2008).
After attention has become more stabilized with basic
breath awareness practice, it is recommended to explore
the wheel of awareness practice, which integrates con-
sciousness by differentiating and then linking the various
elements systematically. By moving the metaphorical
spoke around the rim, the various elements from sight to
bodily sensation to thought can be differentiated along the
rim of the wheel, which holds the wide array of outer and
inner experiences. The rim includes the five basic senses,
the sense of the interior of the body, a sense of mental
activities (thoughts, emotions, and spaces between them),
and of relationships. Clients with limited bodily awareness
can benefit greatly from this exercise as it places the body
in the larger context of a wide range of elements that can be
the focus of attention. Additionally, clients suffering from
depression can use this portion to help disengage the
ruminative brain circuits discussed previously and instead
activate the direct, sensory circuits (Farb et al. 2007).
Eventually in this practice, even awareness itself can
123
Clin Soc Work J (2014) 42:218227
become the focus of attention, however careful preparation
is clinically advised for clients with a tendency to disso-
ciate (Siegel 2010b). For additional information and illus-
trations of the wheel of awareness exercise, please see The
Mindful Brain, The Mindful Therapist, and Mindsight by
Dr. Daniel Siegel (2007, 2010a, b).
Ultimately, when clinicians work with their clients and
themselves, their windows of tolerance can begin to expand
(Siegel 2012a). Differentiating and then linking ones inner
mental life can move the experience of an individual from
chaotic or rigid states toward the more flexible and adap-
tive flow of integration. For example, research has estab-
lished that when people accurately label their emotions,
they activate the middle prefrontal region of the brain. This
is associated with decreases in amygdala activity, a limbic
stems fight or flight response (Creswell et al. 2007). All of
these mindfulness practices are linked to greater brain
integration, which in turn leads to a healthy mind (Siegel
2012a).
In addition to mindfulness training, there are many
practices used to increase compassion for both oneself and
others (Greater Good Science Center 2013). One traditional
practice is loving-kindness meditation, which involves
systematically offering kindness and well wishes to one-
self, a loved one, a neutral person, a difficult person, and
eventually all people (Salzberg 2004). If a person is having
difficulty cultivating self-compassion, it can be helpful to
imagine sending compassion to oneself as a child, or
sending it first to loved ones and then adding oneself to this
group. Another helpful practice used to increase compas-
sion involves looking for similarities and common
humanity between oneself and another person (Greater
Good Science Center 2013). This practice can help set the
foundation for compassion and altruism towards others,
and can be particularly useful in helping increase com-
passion for strangers or those with whom a person has
difficulties. Identifying with another person and recogniz-
ing the shared commonalities that exist can make it easier
to empathize with that persons situation and offer com-
passion. Besides surface level similarities such as age or
gender, people are encouraged to go deeper and find more
meaningful similarities such as the shared desire to be
happy and avoid suffering. Similar to loving-kindness
meditation, it is recommended to start with someone the
client is close with and then gradually expand to a neutral
person, a difficult person, and eventually to all people. If a
client is having difficulty cultivating compassion for
someone, it can be helpful to use the phrases, Just like me,
this person wishes to be (safe, happy, etc.) or, Just like
me, this person has experienced (sadness, joy, loneliness,
etc.), using whatever phrase seems most applicable
(Standen 2012). In addition to these compassion exercises,
Clin Soc Work J (2014) 42:218227
mindfulness meditation has also been linked to increased
compassion for both oneself and others (Condon
et al. 2013; Shapiro et al. 2007).
Over the past year and a half, a team of clinicians and
researchers, including one of the authors, has partnered
with Stanfords Center for Compassion and Altruism
Research and Education (CCARE) to adapt a compassion
cultivation program for veterans suffering from post-trau-
matic stress disorder (PTSD). The team hypothesized that
this training could be beneficial because compassion
practices aim to improve interpersonal and intrapersonal
relationships, which are commonly damaged in people with
PTSD. The majority of veterans in the program reported
difficulties relating to non-veterans, being unable to con-
nect with family members, and having intense feelings of
isolation and guilt. The instructions emphasized personal
choice and autonomy, which included allowing veterans to
choose whether to practice with their eyes open or closed,
and which exercises to participate in. It was also important
to remind the veterans to use only the practices they found
beneficial, as each person had different experiences and
potential triggers. Interestingly, the course instructors
observed that many of the veterans were able to visualize
more vividly than average beginning meditators the guided
positive images of a safe space, or themselves and others
being happy. This offered a powerful counter to their
traumatic memories.
After the 9-week program, instructor observations and
qualitative interviews revealed that many veterans reported
benefits from the class, with some returning to the PTSD
treatment program to re-take the course. When asked what
specifically helped, many veterans said the common
humanity practice described previously helped them better
connect with non-veterans. Many of the veterans also dis-
cussed how self-compassion was a fairly novel concept,
which they noticed increased as the class progressed. Some
veterans discussed how self-compassion could benefit not
only themselves but also their loved ones. Additionally,
multiple veterans reported that the mindfulness component
helped them to calm their minds, sleep better, and become
more aware of their emotional states before acting out.
These findings are supported by a similar, recently pub-
lished study that taught loving-kindness meditation to
veterans with PTSD and found both significant increases in
veterans levels of compassion and reductions in their
PTSD and depression symptoms (Kearney et al. 2013).
Throughout the program the clinicians were able to help
the veterans train their minds to potentially re-wire their
brains. When practicing the compassion exercises men-
tioned above, it is possible that the veterans experienced
increased activation of the anterior insula, which has been
linked to empathy (Gu et al. 2012). It is also possible that
the mindfulness exercises, which consisted of mindfulness
225
of the breath meditation and practicing noticing ones
emotions, potentially led to neural changes to the middle
prefrontal cortex, the center for many regulatory functions
mentioned earlier (Siegel 2007, 2010a). Thus, by working
as neuroarchitects, the clinicians were able to help the
veterans move from chaotic or rigid states to more flexible,
adaptable, and integrated states.
Conclusion
The practice of psychotherapy is an art and science in
which the therapist works as a neuroarchitect to harness the
power of neuroplasticity to move clients toward neural
integration. This ultimately enables the clinician to connect
with the client in such a way that neurobiological changes
can be cultivated and a greater state of well-being devel-
oped. In the interdisciplinary field of interpersonal neuro-
biology, health is seen as emerging from integration, the
linkage of differentiated parts of a system. With integra-
tion, a system flows towards flexibility and adaptability.
When lacking integration, chaos, rigidity, or some combi-
nation of the two, ensue. Disorders can be seen as mani-
festations of impaired integration, with the wide range of
symptoms revealing the chaos or rigidity characteristic of
particular psychiatric disturbances. Clinical evaluation
searches for domains of the individuals life that have
chaos and rigidity, and therefore lack integration. Treat-
ment from this view is integrative as it catalyzes the
linkage of differentiated dimensions of a persons life. The
mind is also seen as a self-organizing, emergent, embodied,
and relational process that regulates the flow of energy and
information within and between us. As clinicians, the most
important starting place to promote integration is to be
presentto have the capacity to be open and receptive to
whatever is happening as it is happening within oneself,
between oneself and others, and within others. Presence
enables the attunement that facilitates a resonance between
client and clinician, an experience of feeling felt that
cultivates trust.
Presence is the heart of the art of therapy, and it is a
capacity that can be learned. Mindful awareness practices
are evidence-based strategies that develop the capacity for
presence. Presence is a winwin situation. It creates hap-
piness, improves immune functions, and helps reduce
burnout (Kane et al. 2007; Irving et al. 2009; Shanafelt
et al. 2012). Presence is also the key ingredient in creating
the integrative communication that is at the core of secure
attachment and effective psychotherapy. In this way,
attachment is an interpersonal form of honoring differences
and promoting compassionate linkagesa form of inte-
grative interpersonal relationship. Mindful awareness
enables an observing circuit to be differentiated from a
123
226
sensing circuit in the brainand then to become linked.
Thus, mindfulness is a form of internal integration.
Clinicians have the opportunity to serve as neuroarchi-
tects and promote internal and interpersonal integration in
their lives and in their work. They can do this through
cultivating mindfulness and presence with themselves and
their clients. Additionally, incorporating the principles of
neuroplasticity in clinical practice is beneficial to the
therapistclient relationship, and harnesses the specific
neural changes that can occur with intentional interaction.
Ultimately, therapists become more resilient, their clients
become more integrated, and their therapeutic relationships
are strengthened.
References
Carr, L., Iacoboni, M., Dubeau, M. C., Mazziotta, J. C., & Lenzi, G.
L. (2003). Neural mechanisms of empathy in humans: A relay
from neural systems for imitation to limbic areas. Proceedings of
the National Academy of Sciences, 100(9), 54975502.
Cassidy, J., & Shaver, P. R. (Eds.). (2008). Handbook of attachment:
Theory, research, and clinical applications (2nd ed.). New York:
Guilford Press.
Christopher, J. C., Chrisman, J. A., Trotter-Mathison, M. J., Schure,
M. B., Dahlen, P., & Christopher, S. B. (2011). Perceptions of
the long-term influence of mindfulness training on counselors
and psychotherapists a qualitative inquiry. Journal of Human-
istic Psychology, 51(3), 318349.
Condon, P., Desbordes, G., Miller, W., DeSteno, D., Hospital, M. G.,
& DeSteno, D. (2013). Meditation increases compassionate
responses to suffering. Psychological Science, 24(10),
21252127.
Craig, A. D. (2003). Interoception: The sense of the physiological
condition of the body. Current Opinion in Neurobiology, 13(4),
500505.
Craig, A. D. (2008). Interoception and emotion: A neuroanatomical
perspective. In M. Lewis, J. M. Haviland-Jones, & L. F. Barrett
(Eds.), Handbook of emotions (pp. 272292). New York, NY:
Guilford Press.
Creswell, J. D., Way, B. M., Eisenberger, N. I., & Lieberman, M. D.
(2007). Neural correlates of dispositional mindfulness during
affect labeling. Psychosomatic Medicine, 69(6), 560565.
Damasio, A., & Carvalho, G. B. (2013). The nature of feelings:
Evolutionary and neurobiological origins. Nature Reviews Neu-
roscience, 14(2), 143152.
Davidson, R. J., & Begley, S. (2012). The emotional life of your
brain: How its unique patterns affect the way you think, feel and
liveand how you can change them. New York: Penguin.
DiNoble, A. (2009). Examining the relationship between adult
attachment style and mindfulness traits. Unpublished doctoral
dissertation, California Graduate Institute of the Chicago School
of Professional Psychology.
Dunn, P. M., Arnetz, B. B., & Homer, L. (2007). Meeting the
imperative to improve physician well-being: Assessment of an
innovative program. Journal of General Internal Medicine,
22(11), 15441552.
Farb, N. A., Anderson, A. K., & Segal, Z. V. (2012). The mindful
brain and emotion regulation in mood disorders. Canadian
Journal of Psychiatry. Revue Canadienne de Psychiatrie, 57(2),
70.
123
Clin Soc Work J (2014) 42:218227
Farb, N. A., Segal, Z. V., Mayberg, H., Bean, J., McKeon, D., Fatima,
Z., et al. (2007). Attending to the present: Mindfulness
meditation reveals distinct neural modes of self-reference. Social
Cognitive and Affective Neuroscience, 2(4), 313322.
Feldman, R. (2007). Parentinfant synchrony: Biological foundations
and developmental outcomes. Current Directions in Psycholog-
ical Science, 16, 340345.
Fredrickson, B. L., Cohn, M. A., Coffey, K. A., Pek, J., & Finkel, S.
M. (2008). Open hearts build lives: Positive emotions, induced
through loving-kindness meditation, build consequential per-
sonal resources. Journal of Personality and Social Psychology,
95(5), 1045.
Geller, S. M., & Greenberg, L. S. (2002). Therapeutic presence:
Therapists experience of presence in the psychotherapy encoun-
ter. Person-Centered & Experiential Psychotherapies, 1(12),
7186.
Germer, C. K. (2009). The mindful path to self-compassion: Freeing
yourself from destructive thoughts and emotions. New York:
Guilford Press.
Goodall, K., Trejnowska, A., & Darling, S. (2012). The relationship
between dispositional mindfulness, attachment security and
emotion regulation. Personality and Individual Differences,
52(5), 622626.
Goodman, M. J., & Schorling, J. B. (2012). A mindfulness course
decreases burnout and improves well-being among healthcare
providers. The International Journal of Psychiatry in Medicine,
43(2), 119128.
Greater Good Science Center. (2013). How to cultivate compassion?
Retrieved from http://greatergood.berkeley.edu/topic/compas
sion/definition.
Grepmair, L., Mitterlehner, F., Loew, T., Bachler, E., Rother, W., &
Nickel, M. (2007). Promoting mindfulness in psychotherapists in
training influences the treatment results of their patients: A
randomized, double-blind, controlled study. Psychotherapy and
Psychosomatics, 76(6), 332338.
Gu, X., Gao, Z., Wang, X., Liu, X., Knight, R. T., Hof, P. R., et al.
(2012). Anterior insular cortex is necessary for empathetic pain
perception. Brain, 135(9), 27262735.
Hasson, U., Ghazanfar, A. A., Galantucci, B., Garrod, S., & Keysers,
C. (2012). Brain-to-brain coupling: A mechanism for creating
and sharing a social world. Trends in Cognitive Sciences, 16(2),
114121.
Henry, W. P., Schacht, T. E., & Strupp, H. H. (1990). Patient and
therapist introject, interpersonal process, and differential psy-
chotherapy outcome. Journal of Consulting and Clinical
Psychology, 58(6), 768.
Iacoboni, M. (2007). Face to face: The neural basis of social mirroring
and empathy. Psychiatric Annals, 37(4), 236241.
Iacoboni, M. (2009). Imitation, empathy, and mirror neurons. Annual
Review of Psychology, 60, 653670.
Irving, J. A., Dobkin, P. L., & Park, J. (2009). Cultivating
mindfulness in health care professionals: A review of empirical
studies of mindfulness-based stress reduction (MBSR). Comple-
mentary Therapies in Clinical Practice, 15(2), 6166.
Jacobs, T. L., Epel, E. S., Lin, J., Blackburn, E. H., Wolkowitz, O. M.,
Bridwell, D. A., et al. (2011). Intensive meditation training,
immune cell telomerase activity, and psychological mediators.
Psychoneuroendocrinology, 36(5), 664681.
Kabat-Zinn, J. (2003). Mindfulness-based interventions in context:
Past, present, and future. Clinical Psychology: Science and
Practice, 10(2), 144156.
Kane, M. J., Brown, L. H., McVay, J. C., Silvia, P. J., Myin-Germeys,
I., & Kwapil, T. R. (2007). For whom the mind wanders, and
when. Psychological Science, 18(7), 614.
Kearney, D. J., Malte, C. A., McManus, C., Martinez, M. E.,
Felleman, B., & Simpson, T. L. (2013). Loving-kindness
Clin Soc Work J (2014) 42:218227
meditation for posttraumatic stress disorder: A pilot study.
Journal of Traumatic Stress, 26(4), 426434.
Klimecki, O. M., Leiberg, S., Lamm, C., & Singer, T. (2013).
Functional neural plasticity and associated changes in positive
affect after compassion training. Cerebral Cortex, 23(7),
15521561.
Krasner, M., Epstein, R., Beckman, H., Suchman, A., Chapman, B.,
Mooney, C., et al. (2009). Association of an educational program
in mindful communication with burnout, empathy, and attitudes
among primary care physicians. JAMA: The Journal of the
American Medical Association, 302(12), 12841293.
Kuyken, W., Watkins, E., Holden, E., White, K., Taylor, R. S.,
Byford, S., et al. (2010). How does mindfulness-based cognitive
therapy work? Behaviour Research and Therapy, 48(11),
11051112.
Lazar, S. W., Kerr, C. E., Wasserman, R. H., Gray, J. R., Greve, D.
N., Treadway, M. T., et al. (2005). Meditation experience is
associated with increased cortical thickness. NeuroReport,
16(17), 1893.
Lutz, A., Brefczynski-Lewis, J., Johnstone, T., & Davidson, R. J.
(2008). Regulation of the neural circuitry of emotion by
compassion meditation: Effects of meditative expertise. PLoS
One, 3(3), e1897.
MacBeth, A., & Gumley, A. (2012). Exploring compassion: A meta-
analysis of the association between self-compassion and psy-
chopathology. Clinical Psychology Review, 32(6), 545552.
Mikulincer, M., & Shaver, P. R. (2007). Boosting attachment security
to promote mental health, prosocial values, and inter-group
tolerance. Psychological Inquiry, 18(3), 139156.
Neff, K. (2003). Self-compassion: An alternative conceptualization of
a healthy attitude toward oneself. Self and Identity, 2(2), 85101.
Neff, K. (2011). Self-compassion: Stop beating yourself up and leave
insecurity behind. New York: HarperCollins e-books.
Neff, K. D. (2012). The science of self-compassion. In C. Germer &
R. Siegel (Eds.), Compassion and wisdom in psychotherapy (pp.
7992). New York: Guilford Press.
Neff, K. D., & McGeehee, P. (2010). Self-compassion and psycho-
logical resilience among adolescents and young adults. Self and
Identity, 9, 225240.
Nelson, B. W., Parker, S. C., & Siegel, D. J. (2013). Interpersonal
neurobiology, mindsight, and the triangle of well-being: The
mind, relationships & the brain. In E. Tronick, B. Perry, & K.
Brandt (Eds.), Infant & early childhood mental health (pp.
129144). Washington, DC: American Psychiatric Publishing.
Parker, S. C, Nelson, B. W., Epel E., Siegel, D. J. (in press). The
science of presence: A central mediator of the interpersonal
benefits of mindfulness. In K. W. Brown, J. D. Creswell, & R.
M. Ryan (Eds.), Handbook of mindfulness: Theory and research.
New York: Guilford Press.
Ryan, R. M., Brown, K. W., & Creswell, J. D. (2007). How
integrative is attachment theory? Unpacking the meaning and
significance of felt security. Psychological Inquiry, 18, 177182.
Salzberg, S. (2004). Lovingkindness: The revolutionary art of
happiness. Boston, MA: Shambhala.
Santorelli, S. F., & Kabat-Zinn, J. (2009). Mindfulness-based stress
reduction professional training resource manual: Integrating
227
mindfulness meditation into medicine and health care. Worces-
ter: University of Massachusetts Medical School.
Shanafelt, T. D., Boone, S., Tan, L., Dyrbye, L. N., Sotile, W., Satele,
D., et al. (2012). Burnout and satisfaction with worklife balance
among US physicians relative to the general US population.
Archives of Internal Medicine, 172(18), 13771385.
Shapiro, S. (2013). Does mindfulness make you more compassionate?
Retrieved from http://greatergood.berkeley.edu/article/item/
does_mindfulness_make_you_compassionate.
Shapiro, S. L., Astin, J. A., Bishop, S. R., & Cordova, M. (2005).
Mindfulness-based stress reduction for health care professionals:
Results from a randomized trial. International Journal of Stress
Management, 12(2), 164.
Shapiro, S. L., Brown, K. W., & Biegel, G. M. (2007). Teaching self-
care to caregivers: Effects of mindfulness-based stress reduction
on the mental health of therapists in training. Training and
Education in Professional Psychology, 1(2), 105.
Shapiro, S. L., Schwartz, G. E., & Bonner, G. (1998). Effects of
mindfulness-based stress reduction on medical and premedical
students. Journal of Behavioral Medicine, 21(6), 581599.
Siegel, D. J. (2007). The mindful brain: Reflection and attunement in
the cultivation of well-being. New York: W.W. Norton &
Company.
Siegel, D. J. (2009). Mindful awareness, mindsight, and neural
integration. The Humanistic Psychologist, 37(2), 137158.
Siegel, D. J. (2010a). The mindful therapist: A clinicians guide to
mindsight and neural integration. New York: W.W. Norton &
Company.
Siegel, D. J. (2010b). Mindsight: The new science of personal
transformation. New York: Bantam.
Siegel, D. J. (2012a). The developing mind, second edition: How
relationships and the brain interact to shape who we are. New
York: Guilford Press.
Siegel, D. J. (2012b). Pocket guide to interpersonal neurobiology: An
integrative handbook of the mind. New York: W.W. Norton &
Company.
Siegel, D. J., & Hartzell, M. (2003). Parenting from the inside out:
How a deeper self-understanding can help you raise children
who thrive. New York: Tarcher.
Sroufe, L. A., Egeland, B., Carlson, E., & Collins, W. A. (2005).
Placing early attachment experiences in developmental context:
The Minnesota longitudinal study. In K. E. Grossmann, K.
Grossmann, & E. Waters (Eds.), Attachment from infancy to
adulthood: The major longitudinal studies (pp. 4870). New
York: Guilford Publications.
Sroufe, L. A. & Siegel, D. J. (2011). The verdict is in: The case for
attachment theory. Psychotherapy Networker, MarchApril.
Standen, A. (2012). Through meditation, veterans relearn compassion.
Retrieved from http://www.npr.org/2012/11/21/165667696/
through-meditation-veterans-relearn-compassion.
Zylowska, L., Ackerman, D. L., Yang, M. H., Farrell, J. L., Horton,
N. L., Hale, T. S., et al. (2008). Mindfulness meditation training
in adults and adolescents with ADHD a feasibility study. Journal
of Attention Disorders, 11(6), 737746.
123