Richard W. Crandall MA, LCMHC, LADC, RCST, PTP

Master of Arts in Counseling

Registered Craniosacral Therapist

Polarity Therapy Professional
Licensed Clinical Mental Health Counselor Vermont Credential # 068.0061316
Licensed Alcohol and Drug Counselor Vermont Credential # 000419

International Certification Co-Occurring Mental Health-Substance Counselor

Business Location: PO Box 58 Burton House 289 Main St. Norwich, VT 05055
Email Crandall.LCMHC

Call or Fax 802-674-6661

Professional Qualifications and Experience
My practice in counseling is reflective and client centered. It ranges from brief, solution-focused to in-depth, long-term work. In addition I am trained in motivational enhanced cognitive behavioral therapy, cognitive behavioral trauma therapy, mindfulness therapy and meditation. I have been in the field of co-occurring mental health and substance use disorders since 1988. I currently provide individual and family counseling to those effected by partner use of substances.  I am certified in motivational enhanced cognitive behavioral therapy. I am a licensed clinical mental health counselor and licensed alcohol and drug counselor in the State of Vermont.I graduated from Franklin Pierce University with a BS in General Studies (1991), and Union Institute and University with a Masters of Arts in Clinical Mental Health Counseling (2007). I have an International Certification to provide co-occuring substance and mental health counseling (2011).

I have holistic therapeutic bodywork training of 880 hours in Polarity Therapy from the Polarity Realization Institute (1994 to1997), training of 1250 hours in Craniosacral Therapy from the Wellness Institute (1999 to 2001) and spent an additional year (2003) assisting my teacher Roger Gilchrist in a Biodynamic Craniosacral Therapy Foundation course. I began my professional polarity practice in 1997 (RPP), changed polarity assiciations in 2015 and practice as a Registered Craniosacral Therapist (RCST) since 2001.   

Each two year period I complete a minimum of 40 continuing education credits for counseling and additional continuing education credits for  Craniosacral therapy. I am a member of the Vermont Mental Health Counselors Association, National Alcohol and Drug Abuse Counselors Association and Vermont Addiction Professional Association. In addition I am also a member of the  Biodynamic Craniosacral Therapy Association of North America and International Polarity Education Alliance. I am currently a member of the Associated Bodywork and Massage Professionals and Associated Psychotherapists of Vermont.

In all but a few circumstances, the privacy and confidentiality of our work together is a privilege of yours and is protected by me, by the law, and by my profession’s ethical standards.  Exceptions are:
- You give me written permission to share information with another person.
- You are incapacitated or in imminent danger of harming yourself or others.
- You indicate evidence or possible exploitation of a minor, an elder or disabled person, in which case, I am mandated to report this to the State of Vermont.
- Your insurance claim requires a psychiatric diagnosis code.  This will become part of your permanent medical record.  Some managed care companies require written or telephone reviews of your treatment.
- Your records are subpoenaed by the court for legal proceedings.
- You make threats of violence to a person or property.  I have a duty to inform the authorities and any intended victim.
- When I need to discuss issues in professional supervision.

HIPPA-Privacy for Mental Health Records and Information Release for Billing Purposes
The Client acknowledges that Richard Warren Crandall has hired Erica Napsy, a medical billing specialist and bookkeeper. She is aware of and in compliance with confidentiality and HIPPA privacy regulations including keeping records safe in a secure location to which no one has access. The Client authorizes Richard Warren Crandall and Erica Napsy to contact the Client’s insurance company to discuss claims submitted for purposes of authorizing payment. The Client authorizes Richard Warren Crandall to share relevant information with the insurance company for the purpose of authorizing sessions.

Legal Issues
I am not an expert witness and do not agree to participate in any legal matters you may have. If I am subpoenaed to court on your behalf, I charge $2500.00 retainer and an hourly fee of $125 per hour in preparation, court time, travel time or for any other time I spend in regard to your case.

In my private practice my intention is to provide a safe environment that allows the client to feel at ease and not judged. This form of reflective life process work allows 
the inner feelings to arise in the present moment from the mind or body which often leads to a healing process. 

Specifically my practice of Substance Use Counseling utilizes evidenced based  approaches of mindfulness and 12 step facilitation. Polarity Wellness counseling supports the client in his or her own healing process of enhancing a healthy life force, greater awareness and  expression of feelings that arise in the moment from the mind or body. Clients may be asked to complete homework of Polarity yoga or light stretching, journaling, and meditation to reduce social anxiety or substance use. Typically in  craniosacral therapy thoughts and feelings may be a brief update expressed before or after the session begins. However in Polarity 60 to 90 minutes can be utilized to examine the life process in greater detail and informs and  contributes to a more complete healing session.

Scheduling and Cancellations
Appointments  are usually 60 minutes. Appointments can  be  more if  you wish. If you need to cancel an appointment please notify me at least 24 hours in advance. If you give less than 24 hours notice of cancellation or if you no show for your counseling appointment I may refer you to someone else. There will be no cancellation fee for severe winter storms, sudden illness, or family emergencies. 

Fee Arrangement
Customary Counseling fee is $110 per hour cash or check, accepted if you do not have insurance I accept.

Therapeutic Bodywork either craniosacral or polarity fee is $70 per hour.

Therapeutic Bodywork Sessions are typically One Dollar per minute. A therapeutic bodywork session of 90 minutes is $85. Full payment(cash or check)is expected at the time of service unless other arrangements are made in advance. You are financially responsible for all charges rendered for service.

BC+BS or Harvard Pilgam or Cigna is accepted for mental health counseling and substance abuse counseling. If you wish to submit your claim for craniosacral therapy Cigna has reimbursed in the past for treating PTSD. You would need to fill out your claim forms and send in the forms to your insurance provider. If you need my help filling out insurance I will do my best to help you. Insurance providers may reimburse you for bodywork. However, Preauthorization is recommended. Also Insurance may reimburse for polarity or craniosacral with (PCP/MD) doctors approval.  Your check or cash payment for therapeutic bodywork is expected at the end of each session.

Authorization of Treatment
Polarity or Craniosacral therapy services to minors and or those with legal guardians must be authorized by a parent or guardian.

If you are not satisfied with your therapeutic bodywork session I will offer your money back or a free session of therapeutic bodywork sessions.

Evaluation and Treatment Complaints
If at any time you feel dissatisfied with any aspect of our work together, please talk with me about it. This can be a very valuable part of our work together.

If you feel you have been treated unethically by me or any other therapist, and cannot resolve this problem, you can contact the licensing board of Professional Regulation, 109 State Street, Montpelier, Vermont 05609 or by phone 802-828-2390802-828-2390.

On the following page is a list of behaviors considered unethical by the mental health profession. The list may guide you in understanding your rights as a client.

Your signature acknowledges that you have been given information regarding confidentiality, billing in keeping with HIPPA, scheduling/cancellation, fees, insurance, authorization for treatment, my professional qualifications and experience, a listing of actions that constitutes unprofessional conduct according to the Vermont Statutes, and the methods for making a consumer inquiry or filing a complaint with the office of Professional Regulations. Your signature also indicates your understanding and agreement to the above stated policy.

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Signature of Client  (Parent/Guardian)        Printed Name        Date

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Signature of therapist                    Date

* A list of actions that constitute unprofessional conduct are attached

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A thesis submitted by Richard W. Crandall
to Vermont College and Union University and Institute
in partial fulfillment of the requirement for the
degree of MASTER OF ARTS in Clinical Mental Health Counseling


Burnout is defined as a syndrome of physical and emotional exhaustion. Burnout affects work satisfaction and performance, and mental health professionals appear to experience burnout symptoms that may affect personal health. Recent research suggests that meditation as treatment may prevent or lesson burnout symptoms. Meditation practice typically occurs either before or after a psychotherapy session. Therapeutic fulcrums an in-session technique for managing vitality may provide an effective means for preventing burnout in the psychotherapist without the necessity of additional time. The therapeutic fulcrum in-session technique is a visualization that may be utilized by the therapist at the beginning or during a therapy session that may improve therapeutic awareness and presence without interfering with therapeutic process or outcome.

Chapter One: Introduction…………..…………………….…………4
Chapter Two: Literature Review….………………………………..14
Chapter Three: Introduction to Action Project…………………….70
Chapter Four: Means of Evaluation………………………………..91
Chapter Five: Summary……………………………………………96



Burnout Defined
Freudenberger (1974, 1975), and Maslach (1976), were the first to define burnout as a syndrome. Burnout appears to be a syndrome of emotional exhaustion, depersonalization, and a feeling of reduced personal accomplishment (Shapiro, Astin, Bishop, & Cordova, 2005). Burnout appears to be caused by emotional demands placed on professional care-givers (Maslach, Schaufeli & Leiter, 2001).
Freudenberger’s (1980), research described burnout as frustration or fatigue due to the failure of a relationship or way of life. Research by Bowen (1978), Kerr and Bowen (1988), suggests that burnout may be the result of an interaction between the psyche and environmental factors. Grosch’s (1994), research suggests that burnout has physiological, behavioral, psychological, and spiritual features that reflect a condition of the body and soul which suggest a loss of faith in personal ideals.

Preventing Burnout
Burnout may be a useful concept for understanding and treating a class of work-related symptoms (Maslach, Schaufeli & Tadeusz, 1993). Research by Baker (2003), Grosch and Olson (1994), sought to understand the dynamics and conflicts associated with burnout. Grosch and Olsen suggest that therapists need to understand how the family of origin patterns may be replicated in the work place. Baker’s research determined that therapists may at times overwork in order to satisfy unconscious goals established by the family of origin. Baker found that if the therapist is able to consciously understand the motivation to overwork, burnout may be prevented.

Younger therapists tend to be at greater risk for burnout (Ackerley, Burnel, Holder & Kurdek, 1988; Sherman & Thelen, 1998). Young therapists may receive less supervision and be in stressful interactions with patients. Freudenberger and Kurtz (1990), report that experienced therapists have a greater degree of confidence, flexibility, and comfort in stressful situations and may suffer less symptoms of burnout compared to young therapists.

Relaxation may be challenging hard work for many therapists (Baker, 2003). Ziegler and Kanas (1986), recommend that training for therapists occur early in order to establish the practice of relaxation. Therapists that do not receive recommendations for self care early in their career may later take extended time away from work. Fowler (2000), the chief executive officer of the American Psychological Association (APA), recommends taking short breaks in order to avoid the need for a leave of absence.

Burnout is a significant issue and self-care is possible when the therapist decides to address the issue (Rothschild, 2000). Burnout may occur if the therapist avoids the inner world of feelings, thoughts, values, and ambitions (Jaffee & Scott, 1984). Staying present within the self allows the therapist to observe personal feelings, increasing the ability to be alert, aware and focused (Baker, 2003). Thus if the therapist is able to remain present to his or her thoughts and feelings the risk of burnout may be lowered.

Therapist presence has been identified as a factor associated with therapeutic outcome and efficacy (Frank, 1977; Mahoney, 1995; Strupp, 1996; Welt & Herron, 1990). Therapist presence describes the ability to deeply listen with empathy toward and commitment to the patient’s welfare (Strupp, 1996). If the therapist is able to be emotionally present he or she may experience less burnout symptoms.
Freudenberger and Robbins (1979), suggest for therapists to constructively pursue sufficient personal resources in order to avoid seeking empowerment through the therapist-patient experience. Goldberg’s (1992), research suggests that the therapist seek personal resources of self-enrichment through uplifting emotions, physical stimulation of exercise, and mental stimulation of improved awareness and consciousness, Treadway (1988), suggests a replenishing activity with the goal of re-energizing the mind, body and spirit. Meditation may be a practice that helps the therapist to restore and maintain personal resources thus avoiding empowerment though the therapist-patient experience.

Statement of the Problem
Meditation has been practiced by practitioners in the East and West around the world for centuries. Buddhist practitioners of the East have been practicing a systematic method of meditation enhancing the inner world of the human being for 2500 years (Goldstein, 1976). Buddhist practitioners report the development of greater calm, compassion and relief from destructive emotions (Goleman, 2003). Meditation practitioners of the west have documented meditation practices since the 14th century (Benson, Berry & Carol, 1974).

Freud on the other hand, believed meditation would produce a regressive and pathological condition within the patient (Epstein, 1984). Freud also believed that meditation and psychotherapy could not be integrated (Epstein). Yet throughout the 20th century individual psychotherapists began to utilize meditation to help themselves. Neo-Freudian psychoanalysts Horney (1945), and Kelman (1960), explored the concepts of meditation and psychotherapy. Carrington and Ephron (1975), and Shafi (1973), reported that a growing number of psychoanalysts were working with meditation and psychotherapy together and that meditation and psychotherapy may be integrated.

In 1977 the American Psychiatric Association (APA), suggested that meditation may enhance the therapeutic process and the APA encouraged research to evaluate its possible usefulness (Task Force on Meditation, 1977). Dr. Benson, a Harvard cardiologist, began to research meditation in the 1960's and determined that the sympathetic nervous system (SNS), may be deactivated with meditation. Benson (1974), referred to these changes as the relaxation response. Benson found that the deactivation of the SNS decreased metabolism, heart rate, blood pressure, breathing rate, and muscle tension (Benson & Stuart, 1992).
Meditation is now one of the most researched of all psychotherapeutic methods (Walsh & Shapiro, 2006). In the United States there are perhaps ten million practitioners and more than 200 million world-wide (Deurr, 2004). Initial research and clinical observations appear to suggest that personal meditation can benefit therapists (Walsh & Shapiro). The stress of being a therapist may lead to burnout, depression, decreased effectiveness and job satisfaction (Shapiro et al. 2005). Meditation may reduce stress, anxiety, depression and improve self compassion in health care professionals (Shapiro, Schwartz & Bonner, 1998). Rubin’s (1985), research indicated that the benefits of meditation have not yet been fully welcomed in psychotherapy.  Benson suggests that benefits of meditation may be experienced by simply sitting quietly while concentrating on an object such as a word, the breath, a sound, visualizing a pleasant pastoral setting and have a “passive attitude” (1975, p. 110). Rabiner and Kearney-Cooke (1998), also suggest that meditation may become an experience of sensing personal essence. The sensing of a personal essence may lead to an awareness of inner thoughts, feelings and body sensations.

Stress Reduction with Meditation
Shannon (2002), reports that chronic stress is defined as a reaction to constant activation of the SNS. This constant elevation of acute stress can lead to physical and psychological stress related disease (Everly et al. 1989). Meditation may reduce the constant elevation of the SNS and perhaps relieve stress in psychotherapists. Shannon reports that meditation has a number of self care, mental health and physical improving qualities. If the therapist continues to practice meditation he or she may experience health improving physiological changes (Torre, 2001).

Mindfulness meditation is from a Buddhist tradition and includes intentionally focusing personal attention on the present moment without judging or reacting (Kabat-Zinn, 1994; Wittine, 1995). Mindfulness meditation implies paying attention in order to develop greater awareness, clarity and acceptance of the present moment experience (Kabat-Zinn, 1994). Mindfulness meditation practitioners focus attention on the task at hand neither judging nor rejecting what is occurring in the present moment (Germer, Siegel & Fulton, 2005). Research may identify mindfulness as a technology for therapists to develop professional qualities and personal well-being (Germer et al. 2005). Research suggests that mindfulness may enhance general well-being (Brown & Ryan, 2003; Reibel, Greeson, Barinard & Rosensweig, 2001; Rosenzweig, Reibel, Greeson, Brainard & Hojat, 2003).
Mindfulness Based Stress Reduction (MBSR), is a well established model for treating hospital patients and health care professionals (Shapiro et al. 2005). Astin’s (1997), research found that MBSR practitioners experience significant decreases in level of depression, anxiety and had a greater sense of control. Schwartz and Bonner (1998), found that MBSR helps increase scores on a measure of spiritual experiences and measure of empathy. This may indicate that MBSR helps improve effectiveness for the psychotherapist.

Christopher, Christopher, Dunnagan, and Schure’s (2006), research examined the effect of MBSR training during the education of healthcare professionals. Christopher et al. suggest implementing a MBSR program during the healthcare professionals’ training in order to reduce burnout. Research by Christopher et al. suggests that MBSR training early in the education of healthcare professionals may help prevent burnout, lead to a reduction of stress, and lead to greater health for the healthcare professional in his or her career.

Shapiro et al. (2005), utilized a randomized trial to examine what effect MBSR may have on currently employed healthcare professionals. The Shapiro study found that to date there has been no MBSR research on the quantitative effects of meditation in preventing burnout in healthcare professionals. Also results indicate that burnout was decreased (10% to 4%) and psychological stress decreased (23% to 11%) with MBSR. In addition an anonymous participant survey suggested that MBSR had a significant impact on the lives of participants, and participants appear to have improved their health by participating in the MBSR randomized trial.
Johnson’s (1989), qualitative study of 12 psychotherapists that meditate did not report any symptoms of burnout. Johnson’s findings indicate that meditating therapists may choose to incorporate conscious techniques, interventions, rituals, and inner attitudes (T I R I A). Therapists that include T I R I A appeared to be enthusiastic about their practice of meditation and working with clients. Johnson reports that the enthusiasm was indicative of good health and no symptoms of burnout.

Chalif’s (2001), research explored the possible link between psychotherapy and mindfulness meditation. The Chalif study recommends utilizing counter-transference as a technique that may help the therapist understand the patient. Chalif refers to Freud’s thoughts about counter-transference and re-frames counter-transference as a means to help the patient grow and reduce the stress of the therapist interaction with the patient. Chalif explores how the therapist may potentially facilitate client growth through the process of counter-transference and reduce stress in the psychotherapist.

In-Session Meditative Technique
    Meditation appears to promote well-being and may prevent burnout by lowering stress in psychotherapists (Johnson, 1989). Therapists who practice meditation have noted fewer burnout symptoms. Therapists, however, may not find the time to learn, practice, or integrate meditation into the personal or professional daily calendar. The application of the in-session meditative technique, therapeutic fulcrums, may suggest a simple meditative technique that does not require additional time for the therapist to gain the benefits, and to experience less stress and fewer burnout symptoms.
    The therapeutic fulcrum in-session technique consists of a visualization of three anatomy points located along the spine and a visualization of a vector or imaginary connection to the earth or floor beneath the therapist. The technique consists of maintaining an awareness of each anatomy point and the associated contact. If the therapist widens the therapeutic awareness to include these anatomy points the therapist may experience a greater therapeutic presence, physical stability and vitality.
    This action research proposes to explore the application of therapeutic fulcrums, an in-session technique that may prevent burnout in practicing psychotherapists. The therapeutic fulcrum in-session technique may provide personal benefits to the therapist while concurrently providing psychotherapy with the patient without negatively affecting the therapeutic process. According to anecdotal accounts, therapists find that therapeutic fulcrums improve the therapist ability to be present and aware of the process and content of the therapeutic session.
    According to Gilchrist (2000), therapeutic fulcrums may assist the therapist and patient in becoming more aware of personal thoughts, feelings, and physical sensations. Sills (2001), suggests that therapeutic fulcrums may help therapists organize their interactions with patients. According to Gilchrist (2000), and Sills (2001), a fulcrum is simply a still center that organizes experience. Therapeutic fulcrums may help the therapist be more at ease with patient interaction and experience less risk of burnout.

Franklyn Sills and Maura Sills have developed a technique employing therapeutic fulcrums as part of Core Process Psychotherapy (CPP). CPP is only available in the United Kingdom and the training is not currently available in the United States. No published study as of 2007 has been done to explore the effectiveness of therapeutic fulcrums in CPP, other forms of psychotherapy or its effectiveness in reducing stress and preventing burnout in the psychotherapist. However, therapeutic fulcrums have been taught to cranial therapists and it appears promising because of anecdotal accounts. The application of therapeutic fulcrums appears to be effective in supporting the therapist in maintaining an awareness of present moment experience which may benefit the therapist in reducing stress and preventing burnout (Sills, 2001).

Verbal or intentional contact may be enhanced by implementing therapeutic fulcrums (Gilchrist, 2000). Beginning with the initial interaction with the patient, Gilchrist and Sills (2001), recommend that a comfort zone or sense of ease with the patient be achieved through awareness of the therapeutic fulcrums (Gilchrist and Sills). When the therapist first encounters the patient, he or she (the patient) may present with a level of mental, emotional or physical discomfort. Sills and Gilchrist recommend that the therapist gently settle into the therapeutic fulcrums while concurrently maintaining an interaction with the patient through a process known as negotiating. Once the therapeutic fulcrums are brought into the awareness of the psychotherapist, the psychotherapist-patient process may be less stressful for the therapist (Sills and Gilchrist).

Sills and Trumbore-Cheney (personal communication, September, 12, 2006), suggest that therapeutic fulcrums may create a sacred space that promotes vital resources for the therapist and patient. When the therapist brings his or her awareness to the therapeutic fulcrums, a settling within the therapist appears to create an opportunity for effective outcomes. Therapeutic fulcrums may help the therapist create a sense of therapeutic presence and moment to moment awareness of subtle psychotherapist-patient interactions such as counter-transference. This may offer the psychotherapist an experience of less stress leading to fewer symptoms of burnout.


Driving Questions
The central questions informing the inquiry of this action research are: Assuming meditation leads to stress reduction and decreased burnout in psychotherapists’, (1) do therapeutic fulcrums provide a particularly significant reduction of stress, and (2) can this lead to a prevention of burnout in psychotherapists?           





Burnout is a term originally used to describe physical and emotional exhaustion experienced by human service workers (Christopher et al. 2006). Human service providers, co-workers and patients may suffer severe consequences from burnout (Jackson & Maslach, 1982; Jackson, Schwab & Schular, 1986). Human service providers are particularly susceptible to stress overload and burnout (Harris, 2001; Moore & Cooper, 1996; Sharkey & Sharples, 2003; Wall, Bolden, Borrill, Carter, Golya & Hardy, 1997). Mental health practitioners may experience severe emotional exhaustion in the workplace (Moore & Cooper, 1996). Coping with burnout and stress may be a significant factor in the career of professional practitioners (Christopher et al. 2006).
Stress may lead to increased burnout (Spicknard, Gabbe & Christensen, 2002). Healthcare providers experience stress that negatively affects personal health (Shapiro et al. 2005). Stress may lead to increased depression (Tyssen, Vaglum, Gronvold & Ekeberg, 2001), reduced job satisfaction (Blegen, 1993; Flanagan & Flanagan, 2002), personal relationship difficulties (Gallegos, Bettinardi-Angres & Talbott, 1990), mental health distress (Jain, Lall, McLaughlin & Johnson, 1996), and suicide (Richings, Khara & McDowell, 1986). Professional effectiveness may also be negatively affected by stress, evidenced by decreased attention (Smith, 1990), less concentration (Askenasy & Lewin, 1996), adversely affected decision-making skills (Klein, 1996; Lehner, Seyed-Solorforough, O’Conner, Sak & Mullin, 1997), and stress may also limit clinician effectiveness in creating strong relationships with patients (Pastone, Gambert, Plutchik, & Plutchik, 1995).
Research has shown that burnout may be an emotional response to persistent stress that progressively diminishes an individual’s innate vital energy (Shiran, 1984). Studies of workers in the United States, Netherlands, and the United Kingdom show that the number of stress related workers compensation claims for mental health has been increasing (Schaufeli & Enzmann, 1998). Therefore, burnout appears to be an increasing concern in several countries.
Burnout Definition
Burnout may be defined as a syndrome of physical and emotional exhaustion which may have developed from a negative attitude about employment, diminished desire to help patients and poor self-concept (Truchot, Keirsebilck & Meyer, 2000). Burnout has also been defined as a chronic affective state that was comprised of three characteristics of emotional exhaustion, physical fatigue and cognitive weariness (Shirom, 1989, 2003). Research has supported the combining of the three characteristics of emotional exhaustion, physical fatigue and cognitive weariness in describing the burnout syndrome (Melamed, Ugarten, Shirom, Kohana, Lerman & Froom, 1999; Shirom, Westman, Shamai & Carel, 1997).
Researchers have identified burnout as a process as opposed to a specific set of symptoms (Rosenberg & Pace, 2006). Corey and Corey (1998), suggest utilizing a continuum which offers a view of burnout as an evolving process with symptoms varying at differing points in a professional’s career and life. Kestnbaum’s (1984), research suggests that burnout may be a process which first appears as a sudden feeling then later becomes a longer cycle of symptoms accompanied by an effort to regain a loss of vitality, but becomes an unresolved struggle.
Burnout may present with physical indications of chronic tiredness and hypertension (Farber, 1990; Pines & Aronson, 1981). Emotional indications of burnout may be hopelessness (Kestnbaum, 1984), cynicism (Friedman, 1985), withdrawal (Jayaratne &Chess, 1984), and a sense of isolation (Piercy & Wetcher, 1987). Burnout may also be perceived as a chronic depletion of the individual’s coping resources resulting from stressful experience such as in the workplace (Toker, Berliner, Melamed, Shapiro & Shirom., 2005).
Burnout Research
Burnout research in the 1980's and 1990's explored the affected populations of teachers, nurses, doctors, social workers and police officers (Shirom, 2003). The concept of burnout may not be new to psychotherapists, however the literature has acknowledged that burnout among psychotherapist is “under-investigated” (Rosenburg and Pace, 2006, p. 87). People-oriented service providers tend to have idealistic goals and may experience emotional exhaustion, mental weariness and physical fatigue (Shirom, 2003).
By 1990 nearly 2,500 publications, books, journal articles, and dissertations on burnout had been written. A large body of literature on burnout exists yet little is available on the subject of burnout in the psychologist (Ackerley, Burnell, Holder & Kurdek, 1988). Literature on burnout and stress in psychotherapists has been completed by several researchers. Rogow’s (1970), research examined psychotherapist disillusionment. Chessick’s (1971), researched the struggles of neophyte psychotherapists. Walfish, Polifka, and Stenmark’s (1985), research examined therapist career satisfaction. Edelwich and Brodsky (1980), Farber (1983), Freudenberger and Richelson (1980), Pines, Aronson & Kafry’s (1981), research examined the nature of burnout in human services.
Farber’s (1985), research reported that 36% of clinical psychologists employed by a state psychological association were emotionally drained and adversely affected at work. Farber’s research found that 6.3% were strongly affected yet 61.2% reported working directly with people was not stressful. Hellman, Morrison, and Abramowitz (1986), reported 78% were very comfortable practicing individual psychotherapy. Ackerley, Burnell, Holder, and Kurdek, (1988), reported that of 562 licensed psychologists 32.7% experienced moderate emotional exhaustion and 39.9% were at the high burnout range.
In a review of burnout among mental health workers, Leiter and Harvie (1996), found that burnout is prominent when workers are prevented from expressing personal values at work. Burnout may appear when people are not given an option to express themselves. In addition excessive caseloads or personnel problems may interrupt the ability to serve patients (Leiter and Harvie), which may also contribute to feelings of stress and inability to control the work environment.
Raquepaw and Miller (1988), in a sample of 68 psychotherapists in Texas, found that demographic variables or treatment orientation were not precise predictors of burnout in therapists. Raquepaw and Miller did observe that psychotherapists at agencies had more burnout symptoms compared to self-employed psychotherapists. Therapist dissatisfaction with the caseload was positively correlated with burnout symptoms (Raquepaw and Miller).
Beemsterboer and Baum (1984), report that a variety of professionals experience burnout. However, Maslach & Jackson (1981), state that professionals in human service are particularly vulnerable to burnout. Psychotherapists are often interacting with patients in stressful situations and may start to feel the effects of burnout (Maslach, 1978). Edelwich and Brodsky (1980), suggest that victims of burnout lose personal energy, idealism and purpose.
Burnout symptoms such as depression, emotional exhaustion or fatigue may appear to be similar to other conditions such as compassion fatigue or secondary traumatic stress (Figley, 1995, 2002), and secondary victimization (Figley, 1982). Compassion fatigue, secondary traumatic stress or secondary victimization may be associated with the negative consequences of the therapist-patient interactions (Rosenberg & Pace, 2006). However, compared to burnout each of these conditions is conceptually different (Rosenberg & Pace).
Burnout research has focused on attitudinal and organizational consequences and its impact on mental health (Cordes & Dougherty, 1993; Maslach, Schaufeli, & Leiter, 2001; Schaufeli & Enzmann, 1998). Evidence now suggests that burnout may negatively affect physical health and be a risk factor for bodily disorders as evidenced by research that examined burnout and vital exhaustion (a construct related to burnout) that may predict cardiovascular disease (CVD; Appels, 1988; Appels & Schouten, 1991A; Hallman, Thomsson, Burrell, Lisspers & Setterlind, 2003). Burnout may also predict Type II diabetes (Melamed, Shiron & Froom, 2003), impaired fertility (Sheiner, Sheiner, Carel, Potashnik & Shoham-Vardi, 2002), and poor self-rated health (Gorter, Eijkmann & Hoogstraten, 2000; Halford, Anderzen & Arnetz, 2003; Kahill, 1988). Toker, et al.’s research suggests there may be an association between burnout and inflammation at the micro-cellular level among women indicating that inflammation may be a precursor to cardiovascular difficulties.
Psychotherapist Burnout
Clinical psychologist Herbert Freudenberger (1974, 1975), coined the term burnout to describe clinicians that were emotionally and physically exhausted, and no longer effectively providing services. Freudenberger’s research (1984), defined the term burnout as a depletion of resources attributed to prolonged and unsuccessful striving towards unrealistic expectations either internally or externally derived. Burnout causes may be intra-psychic, systemic, or interaction between the two (Baker, 2003). System factors that may cause increase risk for burnout are excessive workload, inadequate reward, sense of little control, interpersonal tension, unfairness and value conflicts (Maslach & Leiter, 1999). Personal dynamics that may increase the risk of burnout are narcissistic tendencies (Grosch & Olsen, 1994), and unmet personal needs or conflicts (Freudenberger & Kurtz, 1990).
The challenges of practicing psychotherapy may cause burnout, or emotional depletion, distress, and impairment (Baker, 2003). Figley, Evans, and Villavisanis (1997), report that therapists may experience burnout and impairment. Stress from physical, emotional, mental, interpersonal or professional factors may cause illness such as poor sleep, indigestion, anxiety, and decrease the ability to pay attention (Baker, 2003). The impact of the stressors may be mediated by vitality of the individual’s character or developmental strengths and weaknesses (Baker, 2003).
Professional healthcare providers that experience burnout may offer compromised healthcare (Maslach, 1976, 1978A, 1978B, 1979; Maslach & Jackson, 1978, 1979, 1980; Maslach & Pines, 1977; Pines & Maslach, 1978, 1980; Freudenberger, 1974, 1975). Research indicates that burnout may be a factor in job turnover, absenteeism, and decreased morale (Maslach & Jackson, 1981). Research on burnout appears to be correlated with personal distress, physical exhaustion, use of alcohol or drugs, poor sleep, and relationship difficulties (Maslach & Jackson, 1981). A symptom of burnout appears to be increased emotional exhaustion where workers are no longer able to give emotional support to patients at the psychological level (Maslach & Jackson, 1981). Consequently, workers in human service agencies may view patients negatively and deliver compromised healthcare services (Ryan, 1971; Wills, 1978).
Several researchers have reported that burnout is a syndrome of emotional exhaustion and cynicism that may occur among human service providers (Maslach, 1978A; Maslach& Jackson, 1978, 1981, 1982, 1984). Burnout appears to be a consequence of persistent exposure to emotional pressure (Pines, Aronson & Kafry, 1981). The symptoms of burnout may present as persistent fatigue, insomnia, frustration and depression (Freudenberger, 1974, 1975; Kyriacou & Sutcliffe, 1978; Maslach, 1976; Maslach & Jackson, 1981). Physical indications of burnout may also be lingering colds, headaches and indigestion (Freudenberger, 1974, 1975; Maslach, 1976).
Human service providers may be more vulnerable to burnout (Beemsterboer & Baum, 1984), and suffer a loss of idealism, energy and purpose (Edelwich & Brodsky, 1980). In human service settings workers may experience a loss of concern for the welfare of the patients and offer compromised service (Edelwich & Brodsky, 1980; Maslach, 1978A). Workers who experience burnout may eventually change jobs (Maslach, 1978A; Pines & Kafry, 1978; Taylor-Brown, Johnson, Hunter & Rockowitz, 1981).
Psychotherapists who experience persistent stressful interactions with troubled patients over long hours may experience burnout (Maslach, 1978A). Long hours at work may invite burnout (Pines & Maslach, 1978). Additional factors that may lead to burnout in psychotherapists include the degree of difficulty in patient problems, interactions with chronic patients, time constraints, and long term mental health employment (Maslach, 1978A). The longer a psychologist is employed in the mental health field (Pines & Maslach, 1978), and the more excessive the work loads (Hellman, Morrison & Abramowitz, 1987), the greater the risk for burnout (Raquepaw & Miller, 1989). Other factors that may make burnout more likely are a lack of change in patient case load and discrepancies between patient growth and therapeutic expectations (Kestnbaum, 1984; Maslach, 1978A).
The Maslach Burnout Inventory (MBI; Maslach & Jackson, 1981) appears to be a valid tool for measuring burnout symptoms. The MBI consists of three scales: (1) emotional exhaustion sub-scale for measuring loss of personal energy, (2) depersonalization sub-scale to measure negative or cynical feelings toward others in the work place, and (3) personal accomplishment, a sub-scale to measure success and competence or a reflection of finding meaning in personal work (Raquepaw & Miller, 1989). The existence and degree of burnout in an individual has been measured by the MBI (Maslach & Jackson). If emotional exhaustion and depersonalization sub-scales measure lower scores, and personal accomplishment sub-scales measure higher scores this may indicate increased burnout symptoms (Raquepaw & Miller, 1989). The MBI and a modified therapist version will be utilized to obtain quantitative test results for this action research project. Additionally a review of qualitative research on psychotherapists that meditate and how mediation may be helpful in reducing stress and preventing burnout will be included in the literature review.
Maslach and Jackson’s (1984), research indicates that different job or organizational conditions were associated with the three subscales of emotional exhaustion, depersonalization and feelings of low personal accomplishment. Raquepaw and Miller (1989), suggest that research into the sources of burnout should examine each possible influence upon the subscales of the MBI. However, researchers prior to 1978 considered the MBI subscales to be an undifferentiated unitary concept (Pines & Kafry, 1978; Pines & Maslach, 1978). All three subscales were considered as one concept and were not correlated with possible sources that may influence each sub-scale.
Studies prior to 1990 did not research the effect of burnout on the private practice therapist. Researchers (Maslach & Jackson, 1984), suggest that role clarity and sense of control may be a determining factor in why private practice therapists’ experience with burnout is different. However Maslach & Jackson (1984), found that co-worker support may reduce the likelihood of burnout which appears to suggest that social support may provide relief for psychotherapists.
Research has shown that private practice therapist experiences less stress compared to agency workers (Raquepaw & Miller, 1989; Dupree & Day, 1995; Vredenburgh, Carlozzi & Stein, 1999), and significantly lower emotional exhaustion and depersonalization (Fortener, 2000; Lippert, 2000). The source of burnout may be in the social or situational factors and not the people that experience burnout (Maslach, 1976, 1978A). Other factors that cause stress and may influence agency workers is additional paperwork (Taylor-Brown, Johnson, Hunter & Rockowitz, 1981), meetings with co-workers (Pines & Maslach, 1978), and the quality and quantity of patients (Maslach, 1978A).
Research of burnout in mental health providers has identified three characteristics that appear to describe the burnout effect and impact on the professional life in the mental health setting. These characteristics are (1) emotional exhaustion, (2) negative attitude toward other people, and (3) less ability to fulfill the desire for accomplishment (Glass & Knight, 1996). The literature appears to suggest that burnout is caused by interactions leading to frustration among workers and patients and not by psychopathology (Linehan et al. 2000). Burnout and psychopathology may share similar features but appear to be of different origins (Glass & McKnight, 1996).
Studies have shown a positive correlation between frustrated expectation and burnout (Bloom, Buhrke & Scott, 1988; Kahill, 1986; Stevens & O’Neill, 1983). Also additional research indicates that burnout may occur more frequently in workers that have high job expectations (Cherniss, 1993; Glass & McKnight, 1996). Research does suggest that a high level of job success expectation may leave therapists vulnerable to increased emotional exhaustion (Kestnbaum, 1984; Linehan et al. 2000).
Research has appeared to show that burnout is a consequence of exposure to persistent job stress (Burke & Richardson, 2000; Hobfoll & Shirom, 2000; Shirom, 1989). The persistent stressors that may lead to burnout are work overload, lack of social support or participation, and role ambiguity (Shirom, 2003). Burnout research has shown that the cause is more likely to be job related and situation specific as opposed to emotional distress such as depression (Maslach, Schaufeli & Leiter, 2001).
If a therapist acquires the sense of a net loss of emotional energy, the therapist may not feel able to continue his or her job (Hobfoll & Shirom, 2000). At this stage of the burnout phenomenon there may be no time lag between experiencing stress and the sudden occurrence of the burnout phenomenon (Schaufeli & Enzmann, 1998; Golembiewski & Boss, 1992; Golembiewski, Boudreau, Munzenrider & Lou, 1996; Leiter & Maslach, 2001). A review of these theories has concluded that the consequences of burnout are significant for individuals and organizations (Burke & Richardson, 2000).
Preventing Burnout
Workplace-based interventions to prevent burnout have attempted to reduce stress, yet little or no long term effect in reducing burnout has been identified (Briner & Reynolds, 1999). The exact nature of how stress causes burnout has yet to be identified (Shirom, 2003). A review of the literature suggests that the effect of stress on burnout may be influenced by different types of stress such as role conflict, ambiguity with personal role, persistent stress and job-related stress (Collings, 1999).
The literature does report interventions for the individual. However, interventions identified thus far are treatment based not prevention (Nelson, Quick & Simmons, 2001). Currently there is little evidence to suggest any systems-based interventions that may reduce work place burnout (Sharom, 2003).
The American Psychological Association (APA), Board of Professional Affairs has recognized a significant need for developing proactive models of therapist self-care (Baker, 2003). An APA Division 42 Practice Niche Guide includes a burnout prevention and treatment guide by Thomas M. Skovholt and Len Jennings (APA, 1999). Freudenberger’s (1974), research indicated that individuals who are idealistic, dedicated, and highly committed are at risk for burnout. The individual that neglects his or her need for rest, companionship, vacations or free time may experience burnout (Rothschild & Rand, 2006).
Grosch’s (1994), research suggests that therapists look within themselves, identify and address feelings of depletion, inability to concentrate and physical problems. One example of the manifestation of burnout in the psychotherapist may be shame. According to Morrison (1989), shame is a significant indication of the defeated self in a state of depletion. This may suggest that the therapist is experiencing burnout and Grosch recommends that through self examination and acceptance of thoughts or feelings, therapists may experience a return to health.
Suran and Sheridan (1985), offer a stress and developmental model for understanding burnout, which suggests that burnout may be the result of personal and professional conflicts and tasks that are unresolved. If the therapist chooses to not address the issues of personal and professional conflict, stress may increase. According to Farber (1983), failure to cognitively assess stressors may play a central role in development of stress. Therefore, it appears that if the therapist does not address current stressors, he or she may experience the burnout syndrome.
A possible model for examining the theoretical view of stress and burnout is Hobfoll’s COR theory (Hobfoll & Shirom, 1993, 2000). Individuals appear to respond to the loss of personal resources by seeking other resources (Hobfoll, 1989, 1988). Hobfoll’s COR theory appears to suggest that stress occurs because of one of these three conditions: (1) if resources are threatened, (2) if resources are lost, and (3) if resources are expected and do not manifest (1988, 1998). For example, confrontation may lead to negative consequences and therefore any positive results obtained from the confrontation may not be greater than the stress of the confrontation itself. This stress of confrontation has been shown to be significant in the burnout syndrome (Leiter & Maslach, 1988).
        Hobfoll’s COR theory (1989, 1998), suggests that a depletion of personal resources such as vitality, material possessions and inadequate community support are related to incidence of burnout. Research has shown that workers with depleted personal resources such as vitality may also experience fatigue, emotional exhaustion, cognitive weariness, may appear to be less attractive and less likely to receive support at social gatherings (Curtona & Russell, 1990). Therefore, a negative relationship between therapist’s social support and burnout may exist (Curtona & Russell, 1990).
Studies by Lavandero (1981), Raider (1989), Clark and Vaccaro (1987), suggest that burnout may be understood by assessing the work environment. Studies by Rosenblatt and Mayer (1975), and Rogers (1987), suggest that factors such as inadequate or abusive supervision, strict work schedules, unrealistic expectations and poor support may lead to burnout. If the therapist wants to work, feels adequately reimbursed for work, and is recognized by others, burnout may be prevented (Grosch, 1994). However, additional facts other than the work environment of the therapist may lead to burnout (Bugental, 1990; Guy, 1987; Kottler, 1980).
Interventions to decrease burnout in therapists who work at an agency include decreasing paperwork and administrative responsibilities (Pines & Kafry, 1978; Pines & Maslach, 1978), shortening the length of the work day, taking frequent work breaks and group supervision (Pines & Kafry, 1978; Pines & Maslach, 1978). Additional burnout prevention for therapists who work at an agency could include community based support groups (Pines & Maslach, 1978), psychodrama (Thacker, 1984), and expecting realistic client growth (Kestenbaum, 1984).
Empirical data tend to suggest a variety of personal testimonies about the relationship between spiritual practices, psychological and physical well-being (Miller, 1999). Clinical research has observed the effect of prayer, contemplation, meditation, yoga and ritual in reducing medical symptoms and improving medical outcomes (Emmett, 1999; Pargament, 1997). Spiritual experience may serve as a physical deactivation of the SNS to counter rapid pulse, increased adrenaline and the accelerated feeling of stress (Benson, 1996). Spiritual practices ranging from that offered in formal organized religion to informal personal versions of spiritual practices offer a sense of something infinite [the view of an open plain, the horizon or spacious sky] thus sustaining the practitioner (Zeiss, 1997).
Maslach and Jackson (1981), suggest that research was needed to address the effectiveness of interventions designed to decrease or prevent burnout. Psychotherapists in private practice have been recommended to express personal feelings about the work environment and engage in community-based support groups (Maslach, 1976). Additional burnout prevention techniques for the private practice therapist include physical exercise (Freudenberger, 1974, 1975; Maslach, 1976), regular vacations (Maslach, 1976), taking a walk to a park or meditating (Maslach, 1978B), separating personal life from work life (Maslach, 1978B), and maintaining a balanced diet (Truch, 1980), psychotherapy (Fleischer & Wissler, 1985; Kaslow & Shulman, 1987; Piercy & Wetchler, 1987), and journaling (Baker, 2003). Christopher et al.’s, (2005), research suggests that teaching psychology students self-care as a means to prevent the consequences of burnout may positively affect therapists, coworkers and associated patients (Jackson & Maslach, 1982; Jackson, Schwab, & Schuler, 1986).
Self care techniques are practices an individual may self administer and also appear to support improved health and well-being (Bickley, 1998). Student therapists may find self-care practices benefit their long term educational experience (Baker, 2003; Weiss, 2004). Self care techniques such as mindfulness meditation may help student-therapists to be less reactive to stress, anxiety or patients in crisis (Christopher et al. 2005). Thus, mindfulness practices may help prevent therapist defensiveness and reactive response to interpersonal and relational experience with patients or supervisors (Epstein, 1995; Lesh, 1970; Magid, 2002; Rubin, 1996; Safram, 2003). Student-therapists reported that the semester long course offered by Christopher et al. (2005), had a significant impact on personal and professional lives because of the learned ability to deal more effectively with daily stress (Astin, 1997; Bruce, Young, Turner, Vander Wal, & Linden, 2002; Shapiro et al. 1998).
Shapiro et al.’s (2005), MBSR research reported job burnout decreased from 10% to 4% in a randomized trial of healthcare professionals including physicians, nurses, social workers, physical therapists and psychologists. This study examined the effects of MBSR on burnout among currently employed therapists active in clinical work (Shapiro, et al. 2005). Prior to this date no other study has examined the effects of MBSR on professionals in a healthcare setting active in clinical work.
Typical participant dropout rates for a MBSR trial is under 20% (Kabat-Zinn, 1982; Kabat-Zinn, et al. 1985; Shapiro, et al. 1998). The Shapiro, et al. (2005), study reported a 44% dropout rate which appeared to be caused by a lack of time and increased responsibility. The Shapiro, et al. study recommends future research to explore stress management interventions that do not include additional time commitment or strain. This action research proposal will suggest an in-session meditative technique utilizing therapeutic fulcrums, which may decrease stress and prevent burnout in the psychotherapist.
Qualitative Studies on Preventing Burnout
In a qualitative study by Johnson (1989), 12 psychotherapists reported feeling enthusiastic about meditation, and their personal and professional lives. Johnson suggests enthusiasm may indicate an absence of burnout symptoms.  Johnson reported that all 12 respondents practice transpersonal psychology, have the support of a meditating community of friends and are secure in a personal relationship with God. Maslach and Leiter (1997), suggest that burnout may be erosion in dignity, spirit and soul. Johnson suggests that meditation and having a spiritual practice appears to prevent psychic fatigue or burnout through daily restoration of personal vitality.
In Rubin’s (1987), dissertation, Pathways to Transformation: An Integrative Study of Psychoanalysis and Buddhism, Rubin describes the experience of psychotherapists that meditate. Rubin has experienced within himself and his patients the development of increased awareness and compassion. Rubin suggests that meditation improves his ability to listen to his patients and observe what maybe interfering with his patient’s ability to change. Rubin reports practicing meditation in order to experience peek psychological health. Rubin suggests that the study of meditation and psychotherapy may promote personal growth and development in the therapist.
Figley (2002), states that psychotherapists may tend to bear suffering of their patients, and as a consequence experience burnout. Therapists tend to bear suffering through a desire to be compassionate toward patients as an approach to effective listening. Figley recommends stress management and self-soothing methods in order to prevent burnout.
Rothschild and Rand (2006), and Gilchrist (2006), suggest that therapists may prevent burnout by seeking a comfort zone or felt sense of ease while interacting with friends or family. Rothschild and Rand suggest that therapists may also decline to locate a comfort zone or felt sense of ease when interacting with patients. Rothschild and Rand suggest that it is necessary to include a comfort zone when interacting with patients in order to avoid burnout.
Guy and Liaboe’s (1986), research indicates therapists have less ability to have meaningful relationships as a consequence of burnout. Kottler (1993), states that more than fifty percent of those practicing counseling reduce the number of contacts with friends and family. Thus, without the contact of supportive friends, family and professional cohorts’ counselors may suffer in silence.
Houtkooper (1997), completed a qualitative study of fourteen meditating psychotherapists in private practice. Houtkooper’s research indicates that meditative practice promotes positive affects that nurture and restore the practitioner. Houtkooper reports that meditation practice personally prepares the practitioner by quieting, centering and guiding the attention to moment-to-moment openness of therapeutic process. Houtkooper suggests that the quality of therapeutic openness allows space for the client to heal and becomes a model for healing and health for the practitioner and the patient.
Bergre (1995), states that therapists need to pay attention to personal needs for psychological sustenance. Bergre further states this may not be adequately addressed at the graduate level of education. Mahoney (1997), suggests that therapists need to explore balance and routines of self-care beginning with graduate school experience. O’Conner (2001), suggests that self-care education in the career of the neophyte therapist may prevent burnout.
Kramen-Kahn, and Hansen (1998), suggest that therapists ought to establish self care behaviors within the work place. Therapists are recommended to pay attention to personal care or risk burnout (Germer et al. 2005). Meditation as an intervention that prevents burnout in the therapist has not been researched (Shapiro et al. 2005). The training of therapists to practice mindfulness meditation may promote success in treatment of burnout (Germer et al. 2005).
Recent research studies (Nanda, 2005; Shapiro et al. 2005; & Christopher et al. 2006), suggest that meditation may reduce the effect of burnout in the psychotherapist. Nanda (2005), in a phenomenological inquiry on the effect of mediation on the practice of psychotherapy reports two findings. First, the meditation experience helps the therapist be present and accept what is occurring in the present moment. Secondly, co-researchers who are experienced meditating psychotherapists report that personal and professional transformation has occurred as a result of regular meditative practice.
Co-researchers appear to accept personal thoughts, feelings and somatic experience without judgment. Nanda (2005), reported that co-researchers are more able to express openness with regard to personal thought, feelings and body sensations. Nanda suggests that co-researchers begin to let go of personal expectations of the therapeutic process, and appear to be more aware of what is emerging in the present moment. Two additional recent studies, Shapiro et al. (2005), and Christopher et al. (2006), have found that MBSR is effective in treating burnout. Prior to 2005 no other study has examined the effects of MBSR on actively involved healthcare professionals providing care (Shapiro et al. 2005). Christopher et al. (2006) found that MBSR may lead to preventing burnout in the therapist.
Meditation Research
Meditation has been practiced by practitioners in the East and West around the world for centuries. Eastern Buddhist practitioners have been practicing a systematic method of enhancing the inner world of the human being for 2500 years (Goldstein, 1976). Buddhist practitioners report the development of greater calm, compassion and relief from destructive emotions (Goleman, 2003). Practitioners of the West have documented in The Cloud of Unknowing meditation practices since the 14th century (Benson, Berry & Carol, 1974).
In 1977, the American Psychiatric Association (APA) suggested that meditation may be beneficial for the therapeutic process. Also in 1977 the APA Task Force on Meditation recommended that meditation be researched for its possible usefulness. Psychotherapist Horney (1945), and Kelman (1960), explored the concepts of meditation and psychotherapy. Carrington and Ephron (1975), and Shafi (1973), reported growing numbers of psychoanalysts found meditation and psychotherapy a robust combination. Mediation research studies prior to 1980 explored psychological changes in the body that appeared to be correlated to the effects of meditation (Wallace, Benson & Wilson, 1971).
Dr. Walter B. Cannon, of Harvard Medical School, was the first to identify the flight-or-fight response to stress (Benson & Stuart, 1992). Dr. Cannon’s work described the body’s reaction to physical or emotional threats. Dr. Benson, Associate Professor of Medicine, Harvard Medical School and Program Director of the General Clinical Research Center, Boston City Hospital conducted meditation research in the 1960's (Benson, Berry & Carol, 1974). Benson (1975) was able to identify a simple method for restoring balance to the fight-or-flight response. Benson (1975, 1984) called this the relaxation response.
The relaxation response was first described by Walter B. Hess (1957). This response was first termed trophotropic (Hess, 1957). The relaxation response appears to initiate decreased sympathetic nervous system (SNS), activity and a possible increase of parasympathetic nervous system (PNS), activity (Benson et al. 1974). The regular daily application of a form of meditation Benson termed the relaxation response appears to decrease systolic blood pressure (Benson, Rosner & Marzetta, 1973).
Daily use of the relaxation response in activities where excessive sympathetic nervous system activation is present may prevent serious diseases such as hypertension (Gutmann & Benson, 1971). Sustained SNS activity may create pathology of diseases (Stefano, Fricchione & Esch, 2006). Persistent elevated SNS activity may cause organism difficulties (Esch, Stefano, Fricchione & Benson, 2002; Stefano, 2002; Esch, Fricchione & Benson, 2002; Fricchione, Bilfinger & Stefano, 1996). The daily practice of meditation forms such as Benson’s relaxation response may prevent serious disease associated with sustained elevated levels of SNS activity.
Benson (1974), appears to have been the first to write about the two necessary steps to meditation, (1) to allow the body to settle into a relaxed condition, and (2) direct the mind to focus on an object. Torre’s (2001), research indicates there are many forms of meditation, however, all forms of meditation have two basic principles. First is the focusing of attention (Kabut-Zinn, 1982). Focusing may be achieved by narrowing the attention to a single word, phrase, prayer, sound, pattern of breath, or observed object (Boryenko et al. 1985). Second, the practitioner simultaneously becomes a witness to the experience of thought while maintaining an attitude of non-judgment (Castleman, 1996).
Research appears to have generalized three different forms of meditation practices: (1) Zen meditation which focuses on background perception, (2) Transcendental Mediation (TM), which focuses on a mantra or an object, and (3) Mindfulness Based Stress Reduction (MBSR), which shifts the focus between background and object (Shapiro, 1982). Research has identified three different forms of meditation, but has not identified which method of meditation research is the most appropriate to utilize. To help clarify and suggest which research method may be most appropriate, Caspi and Burleson’s (2005), research has concluded that if the research question explores the treatment of a specific kind of patient and if the goal of the study is to demonstrate an effect, the best design would be a randomized controlled trial (RCT).
Additionally, Caspi and Burleson (2005), recommend that future meditation research be qualitative in design as well as quantitative. Cunningham (2002), Thomas, Harden, and Oakley et al. (2004), have shown that integrating qualitative research with RCT is a robust study. The combination of quantitative and qualitative research data may improve the ability of determining meaningful clinical effects by avoiding type 1 or 2 errors. The combination of quantitative and qualitative research methods may add another layer of understanding to meditation research (Donovan, Mills & Smith et al. 2002).
A body of research is now available describing the uses and effects of meditation (Kelly, 1996). The literature on meditation indicates that it is effective in controlling the body’s physiological response such as blood pressure, chronic pain and production of hormones indicative of stress (Kelly, 1996). Meditation appears to be a process for self-regulation of attention (Barrows, Jacobs, 2002). Meditation appears to orient the mind and body to a spiritual source (Puryear & Thurston, 1975). The National Institute of Health classifies meditation as part of a larger group called mind-body therapy. Mind-body therapies include for example (MBSR), guided imagery, (TM), and progressive muscle relaxation (Caspi & Burleson, 2005). Meditation appears to have benefits including reduction of anxiety, improved sense of well-being, decreased pain, increased awareness of empathy, awareness of emotion, an increased sense of self actualization and responsibility (Alexander, Rainforth & Gelderloos, 1991; Murphy, 1993; Shapiro, 1992; Walsh, 1992).
Houtkooper (1997) reports that meditation enhances the clinical skills of active listening, free association, empathic attunement and inter-subjectivity. Data suggests that the use of meditation may be effective in treating problems ranging from anxiety to schizophrenia (Kutz, Leserman, et al. 1985). Meditation may become a significant therapeutic tool which promotes change and insight (Torre, 2001).
Mindfulness Meditation
Mindfulness is defined as a non-anxious, purposeful and reflective presence that may be applied to cognitive, technical and interpersonal aspects of caring for another (Epstein, 1999, 2003). Mindfulness has origins in a variety of philosophical traditions of the East (Dewey, 1958; James, 1975; Polanyi, 1974). Mindfulness is a Buddhist psychology concept that is applied in the treatment of patients (DeBary, 1972; Kabat-Zinn, 1994).
Mindfulness practitioners pay attention to the process of mental and physical experience with clarity and insight (Varela, Thompson & Rosch, 1991). Mindfulness practitioners appear to be present to moment-by-moment activity without distraction while remaining calm even while accomplishing multiple tasks (Epstein, 2003). Mindfulness as a practice promotes insight (Balint, 1957), presence and reflection (Epstein, 2003).
The mindfulness practitioner pursues the development of four specific qualities: (1) attentive observation of personal perspectives that may bias the interaction with the patient (Polanyi, 1974), (2) critical curiosity in order to witness personal humility (Epstein, 2003), (3) beginners mind or the ability to hold opposing ideas tolerating uncertainty and anxiety (James, 1975), and (4) presence that quickly communicates a sense of mutual understanding (McPhee, 1997).
Western attempts at developing mindfulness habits may be found in Freud (1961), free-floating attention, Rogers (1958), unconditional positive regard, and Feinstein (1994), studies on cognitive biases. Through the promotion of these qualities psychotherapists may improve clinical outcomes, be more aware of personal presence and experience a satisfying personal exchange with patients (Epstein, 2001). Mindfulness may have the potential to deepen the ability to experience a more satisfying professional practice (Epstein, 2001; Zoppi & Epstein, 2002). Epstein (2003, II) suggests the quiet and stillness that accompany the practice of mindfulness may be essential for reflecting upon the practice of psychotherapy.
Since 1979 when Jon Kabat-Zinn established the Mindfulness Center at the Massachusetts Medical School, 250 MBSR programs have helped patients around the world (Davidson & Kabat-Zinn, 2004). The Stress Reduction and Relaxation Program at the University of Massachusetts Medical Center, has treated more than 15,000 patients utilizing a variety of meditative techniques (Fulton, 1990). The continued development of mindfulness-based research may lead to an integrated model of psychotherapy and mindfulness that supports the personal lives and professional careers of psychotherapists (Germer et al. 2005),
Mindfulness-based meditation appears to improve the well-being of therapists (Brown & Ryan, 2003; Reibel, Greeson, Brainard & Rosenzweig, 2001; Rosenzweig, Reibel, Greeson, Brainard & Hojat, 2003). Therapists may utilize mindfulness mediation in order to improve upon the personal experience of engaging with patients (Germer et al. 2005). The benefits derived from mindfulness practice appear to originate from a less reactive autonomic nervous system (Germer et al. 2005). Health benefits from mindfulness practice have been noted by several (Carlson, Speca, Patel & Goodey, 2003, 2004; Reibel, Greeson, Brainard & Rosenzweig, 2001; Roth & Stanley, 2002; Speca, Carlson, Goodey  & Angem, 2000; Williams, Kolar, Reger & Pearson, 2001).
Reasearch in the 1990's suggested meditation may be more than a change in metabolic rate (Jevning, Wallace & Beidenbach, 1992). Scientifically validated MBSR interventions appear to have originated from the work of Jon Kabat-Zinn (1990), and Marsha Linehan’s (1993A), dialectical behavior therapy (DBT). More recent research by Teasdale et al. (2000), indicates how mindfulness-based interventions may effectively treat chronic depression.  Currently there appears to be a rebirth in interest about mindfulness and acceptance-based treatment approaches as evidenced by several recent research publications (Hayes, Follette & Linehan, 2004; Hayes, Masuta, Bissett, Luoma & Guerrero, 2004).
During the past ten years meditation research has mainly focused on mindfulness meditation (Smith, 2004). Mindfulness meditation has shown to be effective in complimentary treatment of physical and emotional diseases (Germer et al. 2005). Critical reviews of mindfulness meditation research have been done by Baer (2003), Bishop (2002), Bonadonna (2003), and Grossman, Niemann, Schmidt, and Walach (2004). Baer’s study examined conditions such as anxiety, binge eating, chronic pain, depression, fibromyalgia, psoriasis, stress and psychological functioning. Baer determined that MBSR appeared effective (Chambless et al. 1998). Bishop (2002), research determined that MBSR was effective in treating emotional and physical diseases.
This next section will be a review of qualitative research regarding why mindfulness is helpful for preventing burnout in the psychotherapist. First, the larger context of mindfulness and its relationship to Buddhism will be presented. Second in this section, how Buddhism may positively affect the health of the psychotherapist and how the therapist may reduce stress and burnout by utilizing the insights of counter transference. Finally, an in-session meditative technique of therapeutic fulcrums will be presented and how it may benefit the psychotherapist.
Integrating Mindfulness Meditation and Psychotherapy
During the past fifteen years scholarly literature has become available that suggests that integration of Buddhist techniques and psychoanalytic theory may improve both the effectiveness of Buddhist techniques and psychoanalytic practice (Houtkooper, 1997). A reason behind this combination may be a common need for many in the East and West to identify a basic cause for human suffering. Epstein’s (1995), research suggests utilizing the analogy of the Greek myth of Narcissus to explore a similar perspective found in Buddhist psychology and psychoanalytic theory. Epstein states that psychotherapists may treat this basic suffering as feelings of inadequacy, whereas Buddhists seek relief from symptoms through the practice of the noble truths.
This blaming of the self for feelings of inadequacy is echoed by W.R. Bion (Epstein, 1995). Psychotherapists tend to help patients identify the feelings of inadequacy as a precondition to treatment (Houtkooper, 1997). The practice of meditation restores the sense of health by addressing the feelings of inadequacy directly. Epstein suggests that the psychoanalytic theory of Freud (the uncovering of repressed desire and anger), thirty years of objection relations treatment of narcissism, and Winnicott’s theory of the “false self” have been an attempt by the field of psychotherapy to address the childhood loss of the personal ideal (1960, p.143). Epstein states that from a Buddhist point of view this is only the beginning of helping the patient.
Houtkooper’s (1997), research suggests that the early psychoanalytic theorists such as Freud and his students did not have a comprehensive approach. Buddhist tradition suggests the embodiment of a process that moves through insight into the true nature of the self (Epstein, 1995). This approach is toward ideal health which includes a transition from the experience of human nature to ideal health (Rubin, 1994). Meditation appears to move the human experience toward being more open, attentive, compassionate and caring about others and the personal self.
The growth of human nature toward health from the Buddhist perspective begins by admitting and accepting the first Noble Truth that the patient has a symptom, the Second Noble Truth, a diagnosis of suffering, the Third Noble Truth a prognosis, and the method of how it may be changed through a treatment plan of the Noble Eightfold Path of right understanding, thought, speech, action, livelihood, effort, mindfulness, concentration and meditation (Rubin, 1995). This Buddhist perspective may promote health in the psychotherapist through a treatment method of meditation that promotes human development.
Rubin’s (1994), research suggests that Buddhism and psychotherapy may integrate by being mindful of moment-to-moment experience while concurrently being conscious of thoughts, and able to sense feelings. Rubin suggests that Buddhism is focused on the present personal process whereas psychotherapy may be focused on content and how it may be influenced by the past or patient transference experience. Thus psychotherapy and Buddhism may compliment each other when the therapist is mindfully paying attention to the process and content of the therapeutic inter action.
Cooper (1995), Rubin (1996), Stern (1994), and Welwood (1984), report that the positive benefits of meditation have not been positively accepted by the field of psychoanalysis. Rubin (1996), and Epstein (1995), report that the capacity of the psychotherapist to listen can be improved by practicing meditation. For example, meditation could be utilized in the field of psychotherapy to obtain Freud’s recommendation for optimal listening (Rubin). Additionally, Buddhist meditation may improve the ability of the psychotherapist to listen more deeply (Finn, 1992). Meditation could lead the therapist to an enhanced ability to process subtle feelings, reducing stress and possibly preventing burnout.
Coltart (1992), states that Buddhist meditation practice is a way of life not just how professionals interact at work. Coltart considers meditation as a commitment to practicing throughout the day and evening. Coltart recommends a meditative approach to interactions with friends and family to be as if in concentration upon an object, or as in remaining aware of the breath. The practice of meditating on a specific point or object or sound is an example of concentration meditation. An example of a Theravada meditation is paying attention to a process such as the in and out flow of the breath. The meditating psychotherapist may develop greater ability to be patient with friends and family, and be able to experience greater negativity (Coltart). This may help the therapist to experience less stress and fewer burnout symptoms in work and social interactions with friends or family.
Finn’s (1992), research suggests meditation may provide the psychotherapist with an opportunity to witness transference as an external event that is an illusion. This transitional event is witnessed as the meditation practitioner enters what Winnicott calls a “transitional experience” between inner and outer mental awareness (Winnicott, 1951, p. 229). Meditation may at this transition between inner and outer mental awareness be creating a space for optimal psychotherapy to occur (Suzuki, 1974; Washburn, 1988).
Fromm’s (1976), research suggests that although improvement of character in patients may not be possible with psychotherapy, it may be possible by following the Four Noble Truths. When a patient acknowledges suffering and recognizes the origin of personal suffering, the patient’s health may improve. Improvement may occur once the patient begins the treatment plan of following the principles of the Eightfold path (Fromm). The psychotherapist’s goal is to help the patient see the cause of personal suffering, come to believe through insight that health is possible, and thereby removing the original cause (Fromm). Health may be achieved with action by the patient once insight leads to a change in behavior (Fromm). If chronic patients could receive help by meditating the psychotherapist may experience less stress and burnout symptoms.
Fromm, Suzuki, and DeMartino (1970), report that practitioners of meditation may enter altered experiences that psychotherapy is unable to duplicate. For example, Rubin’s (1996), research suggests that practitioners of meditation may need psychotherapy treatment for self-induced altered states of mind. Therefore in examples such as self-induced states of mind psychotherapy may be beneficial.
Pitagorsky’s (1996), research suggests that the capacity of a psychotherapist’s ability to listen may be enhanced with non-judgmental awareness achieved through the practice of meditation. When the psychotherapist is aware and attending to the present, he or she may become open to free associations (Pitagorsky). This capacity of the psychotherapist to be open is similar to the openness of a practitioner of meditation (Pitagorsky). Thus meditation and psychotherapy may inform each other and support the meditating therapist in becoming more effective.

Meditation improving Health
Welwood (1986), a psychotherapist and practitioner of meditation reports that a practice of meditation may help practitioners grow and change. Welwood suggests that psychotherapist follow three principles for spiritual development, grounding, letting go, and awakening the heart. Welwood (1984), reported following these three principles, addressed personal issues of narcissism, desensitization and unresolved personal issues. Welwood suggests that meditation appears to be an effective technique for addressing these three issues that may arise for the psychotherapist. Welwood recommends that psychotherapists may address narcissism, desensitization and unresolved personal issues by developing a sense of inner awareness or soul-work in the sense utilized by Jung (1933), Hillman (1976), and Assagioli (1983), that is to have a deep feeling for life. In this context the psychotherapist may develop an open mind, heart and open space (Houtkooper, 1997). The development of an inner awareness of grounding, letting-go and opening space may promote less stress and prevent burnout in the psychotherapist.
Houtkooper’s (1997), research of eleven key informants indicates that having an inner awareness of the heart and body through Buddhist practice prepared each psychotherapist to be more attentive and present in relation to the patient. Informant Shainburg an informant in Houtkooper’s study states that the health of the psychotherapist may be improved through the openness achieved by practicing meditation. Shainburg suggests that talking about the content of psychotherapy may not be sufficient to achieve beneficial outcomes. Healthy beneficial outcomes may be achieved when the psychotherapist and patient openly discuss conscious awareness of moment-to-moment experience of the psychotherapist and patient dialog.
Houtkooper (1997), reports that when the therapist is able to maintain an awareness of the body by listening and feeling of the present, the therapeutic work may become a healing experience. Heider’s (1985), research suggests not struggling to listen to every word of the patient. Instead Heider recommends that the therapist have an approach to patient interaction that is gentle, quiet, and relaxed. Heider suggests that the therapist be more open and receptive to present moment-to-moment experience by allowing the moment to be more felt by the senses and open to patient experience.
Cooper (1997), suggests that Buddhist meditation supports the psychotherapist in understanding and ability to tolerate being with patients in difficult emotional states. Cooper suggests that combining psychotherapy and Buddhism may create concentrated areas of focus and simultaneously widen the view of the psychotherapist to include the process of psychotherapy. Thus the psychotherapist may become more able to observe the process of counter transference and patient self-exploration (Cooper).
    Integration of Psychotherapy and Meditation: A Historical Review of Possible Influences that may have led to the Development of Therapeutic Fulcrums
The literature appears to support the idea that practicing meditation may enhance the psychotherapist’s ability to simultaneously maintain an awareness of personal thoughts and feelings, plus maintain an awareness of the content and moment-to-moment therapeutic process (Chalif, 2001). A mindfulness meditation goal is to improve in the practitioner of meditation the ability to endure difficult emotions and be mindful of an on-going process. Chalif suggests if the therapist utilizes counter-transference in his or her therapeutic relationship with the patient, the therapist may optimize the therapeutic benefit which may lead to an increase of vitality in therapist. Thus if the therapist experiences increased vitality he or she may prevent burnout.
Chalif’s (2001), research defined counter-transference as the therapist’s conscious and unconscious reactions to the patient (Gorkin, 1987). According to Chalif’s interpretation, the conscious and unconscious reactions experienced by the therapist may originate from the patient, therapist, or both (Chalif). If the psychotherapist could simultaneously observe and engage with counter-transference and the content of the therapist-patient interactions the outcome may benefit the therapist and patient.
Chalif (2001), explored how awareness of counter-transference and a form of mindfulness meditation, Vipassanna, may be utilized as a tool for improving the effectiveness of psychotherapist-patient interactions. Vipassanna meditation attends to the process of breathing in and out, and helps the practitioner to be more mindful of moment-to-moment experience. Chalif suggests that Vipassanna meditation may facilitate more awareness of the subtle thoughts and feelings a psychotherapist may encounter.     
Vipassanna meditation, a form of mindfulness meditation, may help the psychotherapist maintain awareness of the breath and enhance the therapist’s ability to utilize counter-transference. When the practitioner of meditation focuses on the breath he or she may broaden the ability to encounter more difficult emotions or thoughts. Thus the therapist is more able to feel or be present with a previously difficult emotion through the practice of meditation (Bollas, 1987).
Meditation may assist the psychotherapist in utilizing the breath as a centering force for thoughts or feelings being experienced by the meditating therapist. This improved ability to be more able to endure thoughts and feelings may create a new experience or space between action and thought, impulse and restraint. It is through monitoring the breath that meditation may help the practice of the meditating-psychotherapist maintain vitality, reducing stress and preventing burnout.
Freud’s (1913), research recognized that patients were able to combine conscious knowing with not knowing. Freud’s attempt to understand this type of patient conflict led to the discovery of counter-transference. Freud initially thought that counter transference ought to be recognized and overcome (1910). Freud’s initial reaction was two years later modified into a broader view of having “evenly-suspended attention” (1912, p. 111). This change in the psychotherapist reaction to the counter-transference phenomena may have led to greater range of interaction for the therapist and patient (Chalif, 2001).
Freud (1912), wrote that psychotherapists ought to simply listen, and allow the unconscious to become part of the therapeutic relationship. These simple words helped create a change in the psychotherapist’s attending that appears very similar to Buddhist meditation. Freud’s (1912), research suggests that if the psychotherapist is able to be open, free of constraints or purpose, the patient may receive the greatest benefit. Freud’s (1910), research considered successful psychotherapeutic treatment a function of the psychotherapist’s ability to have a completely open mind and be present to the patient’s unconsciousness.
Some twenty-five years later in the evolution of psychotherapeutic attending, Reid (1948), stated that the psychotherapist needs to include the skill of simultaneously experiencing silence and the communication that occurs between two minds. Reik called this capacity to listen a “third ear” (p. 144). Reik also reported that the third ear has the capacity to listen inwardly to thought that is normally drowned out, or to listen to what people do not say but think and feel.
Freud’s (1912), writing appears to be an attempt to clarify the psychotherapist approach to being present with the patient. Freud wrote that the psychotherapist should surrender to present unconscious activity with an attitude of “evenly suspended attention” (1912, p. 111), and listen to the unconscious of the patient from the perspective of the unconscious. It was in this psychotherapist-patient experience of conscious-unconscious and power of observation by the participants that the clinical space was created (Sullivan, 1954). It is in this dynamic space of psychotherapist-patient interchange that a dynamic process may be initiated and perhaps become supportive of both therapist and patient promoting less stress and preventing burnout.
Freud’s (1910), research appears to have initially considered counter-transference a pathological reaction to the patient thoughts or feelings. Heiman’s (1950), research suggested that the psychotherapist could utilize counter-transference to research what the patient was experiencing on an unconscious level. Heimann was able to differentiate personal feelings and thoughts from the counter transference experience. Heimann then recognized how best to utilize counter-transference to serve the patient. This capacity to tolerate the experiences of patient thoughts, feelings and psychotherapy can be draining (Welt & Herron, 1990). However, mindfulness meditation may help the psychotherapist experience both without becoming exhausted. Heimann apparently was able to utilize Freud’s (1912, p. 111), concept of “evenly suspended attention,” and shed light upon how it may be applied in therapy to produce a dynamic outcome for the patient. Heimann’s (1950), notion appears to have nudged the therapeutic field of knowledge and practice toward a relationship model, for Sullivan continued this evolution by suggesting that a psychotherapist’s instrument of discovery is himself, as the observer.
The notion that the field of psychotherapy and Buddhism are informing each other is amplified by the work of Sullivan (1954). Sullivan suggests that the psychotherapeutic-patient interaction and the outcome may be created between the two parties involved.  Sullivan thus introduced the concept of concurrently being an observer and participant which is similar to the Buddhist concept of being the observer and concurrently being actively aware.
Bion (1967, 1970), appears to describe the psychotherapist-patient interaction as an experience that is being informed by present moment experience. Bion’s (1970), research suggests that the attending psychotherapist may observe through the unconscious what the patient is not able to express. Bion suggests that the psychotherapist ought to avoid thinking about the past or having an agenda, but stay focused on the moment to moment experience. Bion suggests that with a practice of meditation the psychotherapist can enhance the powers of observation and remain open to the unconscious communication that occurs in the moment (1967), thus utilizing the present moment experience to remain vital.
Carpy (1989), acknowledges that the psychotherapist’s awareness of the unconscious experience helps the patient. Carpy suggests that if the psychotherapist is able to effectively interpret or tolerate the unconscious experience, the patient may be able to bring forth previously unavailable information. The link provided by the therapist to the unconscious becomes a bridge for the patient to express what was just beneath the consciousness (Carpy). Thus, as the psychotherapist is able to process the patient’s thoughts and feelings through the unconscious link, the patient experiences a new level of understanding, feels heard and becomes aware in a greater way (Carpy). Thus this growth achieved by the patient may be experienced as less stress placed on the therapist.
As previously stated, Freud’s (1910), view that the psychotherapist should consider counter transference a hindrance was reassessed and reevaluated as a helpful method for effective therapy (1912). Since then, there have been various definitions of counter transference (Chalif, 2003; Welt & Herron, 1990), however there appears to be a common understanding at this time (Gabbard, 1995). Counter-transference appears to offer the therapist an effective psychotherapeutic method for understanding and helping the patient (Abend, 1989).
Kahn’s (1991), research suggests that psychotherapists utilize counter-transference to gain insights into the experience that patients may be having. Kahn appears to take advantage of the counter transference phenomenon in order to lower the stress of feeling the patient’s experience too intensely. Kahn suggests pursuing an “optimal distance” (p. 121) from the patient in order to reduce the intensity and reduce the emotional strain.
The “optimal distance” suggested by Kahn (1991, p.121) describes a process where the therapist is able to be an observer of thoughts and feelings of the patient and be less reactive toward the patient. The ability to achieve some space or distance between experiencing and reacting too the patient is supported by mindfulness practice and may be somewhat strengthened by the application of therapeutic fulcrums which is a technique suggested by Franklyn Sills (2000) and Roger Gilchrist (2001).
The ability to be the observer and listen with attention was described by Freud (Freedman, 1982, p. 406), and Reik (Freedman, 1982, p. 407), as a continuous shifting between receiving and attending (Freedman, 1983). When the therapist is unable to maintain a shifting between listening and focused attending, counter transference occurs (Freedman). However, when the psychotherapist is able to maintain awareness of both, simultaneously through having an optimal distance, patient health or vitality can return (Winnicott, 1971).
Winnicott referred to this ability to maintain distance between listening and focused attention as “potential space” (1971, p. 47). Winnicott suggests that by being in the potential space the therapist is optimizing the therapeutic relationship and models a skill that brings a flow [being in the flow of a process but free from attachment to outcome] back in a patient’s life (1971). The skill of maintaining this optimal distance may be enhanced or developed through the practice of therapeutic fulcrums a form of mindfulness meditation. The application of therapeutic fulcrums offers a meditative in-session benefit for the therapist that may lead to less stress and a prevention of burnout in the psychotherapist.
Ogden (1986), referred to Winnicott’s “potential space” (1971, p. 47) as an area that lies between the inner and outer view of the patient’s life. Ogden suggests that if the therapist can model the stance of optimal distance the patient may be able to begin observation of personal reactions to thoughts and feelings. Ogden appears to suggest that creation of space between experiencing thought and reactions by the therapist allows the patient to respond with more space between thought and reaction. Winnicott’s “potential space” appears to help the practitioner provide a more effective treatment and may reduce stress for the therapist.
Winnicott’s (1951), research describes the area of space as a place where inner and outer thoughts and feelings may potentially contribute to each other. Winnicott points out that it is the task of the individual person to keep each inner and outer life experience separate, but to a degree related. Winnicott states that humans will always be negotiating the inner and outer life and that relief from this struggle can be achieved through an area or space that is not intruded upon (1951).
Casement’s (1985), research clarifies Winnicott’s (1951), notion of maintaining an area that is not intruded upon. Casement suggests that the task of the psychotherapist is to hold emotional reactions while considering a response. Casement suggests that this holding process may positively affect the patient by providing a model of how the current emotional experience may be tolerated. This ability to model a different way of experiencing and processing emotions may help the patient see that it can be helpful (Casement). It is the hypothesis of this action research that by applying therapeutic fulcrums the practitioner may also strengthen the ability to endure the emotional experience and feel relief from the stress of patient interaction.
Winnicott’s (1958), research calls this a new way of being with patients. The patient may see the psychotherapist experience emotions and learn how to react in a different way. Bion states that patients may then have an opportunity to be more open to change (Casement, 1985).
Ogden (1994), describes the interaction of the therapist-patient relationship as if there is a third person in the room with the therapist and patient. Ogden refers to this as “the analytic third” and suggests that “the analytic third” is a product of the therapist-patient interaction (1994, p. 171). Ogden promotes this concept as a means of understanding counter-transference. This participant-observer, therapist-patient interaction appears to create a space for a third set of eyes that inform both the therapist and patient. This participant-observer, therapist-patient interaction appears to create a space similar to mindfulness meditation (Ogden).
Jacobs (1986), has found that communication difficulties with the patient may arise when the therapist has trouble perceiving counter-transference data. Jacobs suggests that if the therapist loses concentration of what is occurring in the moment-to-moment action of the patient-therapist interchange, and responds in a reactive mode, difficulties may arise. A possible remedy for this is what Sandler calls “free-floating responsiveness” (1976, p. 45). Sandler’s intervention may lead to subtle cooperative interchanges with the patient through the use of silences and neutrality. Therapeutic fulcrums may offer a technique that deepens the therapeutic experience of neutrality, which may also lower stress and prevent burnout.
Jacobs’ (1986), uses of silence may be recognized as a method of empathic understanding and may at times shut-off the flow of counter-transference communication. Jacobs appears to be suggesting that the therapist can at times be the observer without being the participant. However, when the therapist employs the method of “free floating attention” by maintaining awareness to both [observer and participant] sides, the conscious-unconscious experience may become known to the therapist (Sandler, 1976, p. 45). Thus, the therapist may be able to provide a more effective treatment by maintaining the relationship of listening to both the observer and participant experiences of counter-transference. If the therapist is able to maintain or return to an awareness of the therapeutic fulcrums, “free floating attention” may return and both sides of the conscious-unconscious experience may become known to the psychotherapist and reduce stress for the therapist.
Jacobs (1986), suggests that neutrality is also associated with counter-transference. Jacobs describes neutrality as a state of receptivity in the therapist. Jacobs reports that the inner thoughts and feelings of the therapist need to be in a state of neutrality in order to present a neutral response to the patient. This inner and outer state of neutrality has not been explored by other researchers (Jacobs). This tension within the therapist may lead to inaccurate interpretations of the counter-transference phenomena. This subtle experience of listening to the inner responses may be more effectively responded to if the therapist either meditated or utilized therapeutic fulcrums during the therapist-patient interactions. Jacobs suggests that if the therapist emphasizes either the outer or inner form of neutrality the most effective use of neutrality will not be found.
Mitchell (1997), reports that psychotherapists may at times interact with the patient from the perspective of the counter-transference viewpoint. This counter-transference viewpoint may be that of the patient’s thoughts and feelings. This example reaffirms Mitchell’s perspective that the therapist-patient interrelationship is a shared mental experience as well. The origins of this shared mental experience concept appeared to be from the work of Klein. Mitchell appears to have continued Klein’s work by stating the analytical data that occur within the patient-therapist interaction are no longer found in the mind of just the patient, but in the mind of the therapist as well. This shared mind experience of the therapist with the patient would perhaps suggest why it is so easy for the therapist to become fatigued. It would also suggest that if the therapist could employ a means of maintaining vitality with the application of therapeutic fulcrums it may prove beneficial in relieving stress for the therapist.
Sullivan’s (1954), research introduced the concept of observer-participant. This concept suggests that the therapist simultaneously observe personal feelings and thoughts while concurrently engaging in patient therapy. Sullivan’s observer-participant concept may have been the early shift towards a combined model of relationship based therapy that was to emerge forty years later. The model appears to have combined the psychoanalytic theories of shared psychoanalytic process (Mitchell, 1997), “potential space” (Winnicott, 1971, p. 47), and “analytic third” (Ogden, 1994, p. 171). Each concept utilizes a common experience between the therapist and patient.
Aron suggests that the therapist utilizing the method of observer-participant is not only an observer but also becomes observed (1996). Aron is suggesting that the total effect of being in a patient-therapist interchange is a function of the patient and the therapist. Each may impact the other whether verbal or nonverbal (Jacobs, 1986). This reaction to one another in the therapeutic relationship has been termed “enactment” (Jacobs, 1986, p. 42).
Renik (1993), suggests that counter-transference is in response to an enactment. Renik describes this process as one where the therapist or patient experiences thoughts and feelings before the interpretation of the thoughts and feelings has occurred. Thus the enactment is the possible disturbance that lies below the level of understanding yet becomes a reaction. This is where the application of therapeutic fulcrums may help the therapist maintain an awareness of the counter-transference phenomena without reacting. Maintaining the awareness of the current experience becomes a bridge for the therapist (Sullivan, 1954; Aron, 1996; Ogden, 1986), to associate the external world with the internal world of thoughts and feelings (Aron, 1996) of the patient.
Bion (1970), and Boxhall (2006), suggest that thoughts and feelings are not a process taking place within one person, but are an interaction between two people. Mitchell and Aron (1999), suggest this is a co-mingling of conscious and unconscious experience. Mitchell (1997), states that thoughts and feelings are taking place between two people and not in the mind of one person. It is the suggestion of this action research that the practice of applying therapeutic fulcrums may help the therapist in maintaining an awareness of the conscious-unconscious patient experience and reduce stress by providing support for the therapist-patient interaction.
Chalif (1989), and Jealous (2001), suggest that restoration of health may occur if the therapist seeks to create a space or in-between place of therapist-patient interaction. It appears that Mitchell and Aron have a similar suggestion. Mitchell and Aron (1999), suggest that if the therapist maintains the ability to be aware of personal thoughts and feelings and simultaneously experiences the thoughts and feelings of the patients, the potential for restoring health may be created. When the therapist is able to hold both the experience of him or herself, and the patient this appears to be holding a space that creates the potential for health. It is the suggestion of this action research that therapeutic fulcrums may support the therapist in creating a space for the therapist-patient interaction, which may provide the benefits of reduced stress and prevention of burnout in the psychotherapist.
Winnicott’s (1958), research suggests that in order to achieve an effective outcome for the patient the therapist should establish personal presence. Winnicott utilizes therapist presence as a means of supporting the patient in the process of coming into the present moment. Epstein (1995), reports that the use of silence may help the patient in this process of coming into the present moment. Silence here is used to help the patient obtain a sense of themselves (Epstein, 1995).
The application of therapeutic fulcrums may also be an effective technique for developing presence (Gilchrist, 2001). Therapeutic fulcrums (Sills, 2000), may help the therapist to establish a presence in relation to the patient. It is this establishment of a presence that may create space between the patient and therapist, and patient reaction to experience (Sills and Gilchrist). The practice of meditation [such as therapeutic fulcrums] may cultivate space between the therapist and patient (Epstein, 1998). This establishment of space between the therapist and patient may revitalize the therapeutic presence (Sills, 2000), and lead to less stress and the prevention of burnout for the psychotherapist.
Epstein’s (1998), research suggests that the practice of meditation not only cultivates space between the therapist and patient, but also supports the vitality of the individual to flow. In addition Epstein reports that meditation may support the individual in exploring the thoughts and feelings of inner personal experience. Epstein suggests that a practice of meditation may help the individual become aware of his or her inner essence (Sills, 2000; Gilchrist, 2001).
Epstein (1998), reports that the therapist may utilize meditation to address the issue of overflowing thoughts and feelings. Epstein suggests that meditation may access the core of the experience in session and potentially help the patient achieve a similar awareness and reduction of stress caused by the overflow of thoughts and feelings. The process of deepening the sense of the felt emotions with meditation may help the individual embrace the moment-to-moment experience (Epstein). The application of therapeutic fulcrums may facilitate the process of deepening into the experience of emotions and finding relief from the overflow of thoughts and perhaps lead to a decrease of stress leaving the therapist more vital and able to prevent the symptoms of burnout.
Cooper (1999), wrote an article on Buddhist meditation, and counter-transference which describes the similarities of mindfulness meditation and counter-transference. Cooper suggests that mindfulness meditation may support therapeutic work with patients. Cooper reports that the practice of meditation improves the individual’s ability to focus on the therapeutic experience of counter-transference. Cooper states that combining psychoanalytic theory and mindfulness meditation creates a new perspective of interacting with others.
Molino (1998), describes a view of Buddhism or Eastern psychology and counter-transference as he reviews Alexander’s (1931), link between Freud and Buddha. Molino does not go into the details about the analytical method or doctrine of Buddha. Molino states the philosophy of Buddhist psychology and Western psychotherapy share the belief that overcoming emotional resistance and narcissism was at first thought to be necessary. Molino states both Freud and Buddha later came to the conclusion that addressing the emotional resistance and narcissism led to a connection with consciousness. It is the suggestion of this action research that the application of therapeutic fulcrums may help the therapist become aware of the internal experience of thoughts or emotions, and begin to become aware of and connect to the inner world of consciousness thereby reducing stress and leading to a possible prevention of burnout.
Epstein’s (1998), research describes the initial stages of meditation and analysis as an attempt to clarify the hidden mental processes and adapt to the internal flow of personal experience. Thus as the therapist is able to remain aware of the inner and outer experience or thoughts and emotions the two may mingle and establish a flow of health (Chadron, 1994). This flow of health may support the therapist in maintaining vitality, reducing stress and preventing burnout.
Fulcrums in Healthcare
The concept of fulcrums in the field of healthcare was first explored by Dr. William Garner Sutherland. Dr. Sutherland was a student of Dr. Andrew Taylor Still, the founder of the science of osteopathy. The science of osteopathy includes the fields of physiology, anatomy and philosophy (American Osteopathic Association, 1979).
Dr. Sutherland explored the physiology and function of the human body and how health could be restored. Dr. Sutherland specialized in the study of the cranial mechanism and how health for the whole body may be restored through treating the cranium. Dr. Sutherland, in 1899, was a student of Dr. Still and was intrigued by the design of the cranial bones and how the bones appear to respond to subtle intrinsic movements of the cerebrospinal fluid (CSF), and primary respiration. Dr. Sutherland spent the next thirty years researching the subtle movements of the cranium and how these movements relate to the health of the whole body (Sutherland, 1990).
The cranial concept devised by Dr. Sutherland was comprised of five principles: (1) the CSF fluctuates and has a vital movement termed the tide, (2) the cranial anatomy includes a membrane system that responds to whole-body tension, (3) the neural tube within the craniosacral system exhibits subtle movement, (4) the cranial bones express subtle movement, and (5) the pelvic bones of the sacrum, and ilia are moved in response to the action of the CSF tide. This entire set of principles was identified as an integrated system by Dr. Sutherland and named the “primary respiratory mechanism” (Sutherland, 1990, p. x).
The primary respiratory concept developed by Dr. Sutherland was comprised of five principles which also included physiologic centers that function as a whole to provide health for the entire body. Dr. Still considered health to be an expression of the whole body response to an “eternal law of life and motion” (Sutherland, 1990, p. x). Dr. Still considered health in the body to be demonstrated as a continuous flow of motion on a very subtle level throughout the entire body. Dr. Sutherland considered this subtle action and continuous flow of motion to be an expression of life and the CSF.
Dr. Sutherland’s cranial concept of primary respiratory mechanism appears to demonstrate that the human body has an intrinsic rhythm which maintains a cycle of life in motion (Upledger, 1997). Dr. Sutherland (1990, 2002), Upledger, (1997), Sills (2001), Gilchrist (2006), considered the movement of the CSF to be an essential component necessary for the maintenance of health for the human body. Dr. Upledger a clinical researcher and professor of bio-mechanics led a team of bio-engineers, bio-physicists, physiologists and anatomists at Michigan State University from 1975-1983. Dr. Upledger’s’ findings confirmed Dr. Sutherlands’ 30 years of research regarding the function of the cranial mechanism and the primary respiratory concept.
Dr. Sutherland considered the posterior bones of the head at the occipital bone and just anterior to the occipital bone at the 4th ventricle to be a significant physiologic location for health maintenance. Dr. Sutherland considered this 4th ventricle, a respiratory center that responds to CSF, to be a significant feature and representative of health for the entire body. Dr. Sutherland suggests that if health could be maintained or restored by the flow of CSF in the 4th ventricle, health might be restored throughout the entire body.
At the occipital bone there is a bony protrusion called the external occipital protuberance (EOP). Just anterior to the EOP is a junction of two membranes, the falx cerebri and tentorium cerebelli. The junction of the falx cerebri and tentorium cerebelli is considered to be a fulcrum. Dr. Harold I. Magoun called this significant functional joining of two membranes the “Sutherland Fulcrum” (Magoun, 1951, p. 39).
The fulcrum at the joining of the falx cerebri and tentorium cerebelli membranes provides a still point for the tissues to balance. Similar to a balance scale and its central point of balance, the fulcrum is the point over which balance occurs. The falx cerebri and tentorium cerebelli are membranes (tissues), that shift back and forth over the still point of the fulcrum.
Dr. Edith Dovesmith, in 1918, offered another description of the fulcrum when she compared the action of the back and forth movements of the falx cerebri and tentorium cerebelli over the still point of the fulcrum to a square dance (American School of Osteopathy).The partners in a square dance tend to move back and forth or to-and-fro, yet maintain a balance point over which the action is still. This movement tends to occur around the still point of the fulcrum that exists between the two dancing partners.
Sutherland’s fulcrum is formed just anterior to the EOP at the internal occipital protuberance (IOP) where the falx cerebri and tentorium cerebelli join. The falx cerebri and tentorium cerebelli extend from the IOP towards the facial bones and secure the sutures of the cranial bones and crista galli of the ethmoid bone, frontal bone, the two parietal bones and occipital bone (Sutherland, 1990). The inferior surface or sagittal plane of the falx cerebri descends between the cerebral hemispheres (Sutherland, 1990). The tentorium cerebelli covers the entire cerebellum. The superior edge of the falx cerebri in combination with the bilateral membrane of the tentorium cerebella, are in a constant state of tension and movement (Sutherland, 1990).
The constant state of tension appears to be caused by the cranial system of bones and membranes always being in subtle motion. According to Sutherland’s cranial concept the entire bony structure and membrane system is in constant back and forth movement at the still point of the fulcrum located just anterior to the IOP. Sutherland called this action a “reciprocating tension membrane” (1990, p. 42).
The fulcrum at the joining of the falx cerebri and tentorium cerebelli is a balance point for the entire membrane system in the cranium (Sutherland, 1990, 2002; Sills, 2001, 2004). The fulcrum here is similar to a lever such as a crowbar which is utilized to move a heavy object. The lever over a still point has a mechanical advantage and expresses more power than a pair of hands could have. The lever over this still point may be shifted to-and-fro, back and forth, in order to maintain balance and health in the cranium. Sutherland suggests that if the balance point at this fulcrum is located through the felt sense of the cranial therapist, the cranial system will settle into a state of balanced tension.
    The cranial therapist utilizes his or her hands to feel the still point of Sutherland’s fulcrum and affect the function of the body. When the cranial therapist is able to sense the location of the still point of the fulcrum the shifting falx cerebri and tentorium cerebelli membranes begin to find balance and express a sense of ease. When the cranial therapist locates the still point of Sutherland’s fulcrum at the 4th ventricle, he or she may treat all the physiological centers of the body including respiration, heart, vasomotor, vomiting and membrane system (Wright, 1928; Sutherland, 1990). When the cranial therapist locates the felt sense of tension at the still point of the fulcrum and slightly retreats his or her hand pressure and presence, the cranial system may begin to find balance and restore health in the body. The cranial therapist utilizes therapeutic fulcrums to help in obtaining the subtle nuances and awareness needed to become aware of the still point at Sutherlands fulcrum.
Fulcrums: Natural, Inertial and Therapeutic
Sutherland’s fulcrum is one of three naturally occurring points of balance which revitalize and maintain health of the physiologic centers in the human body. The additional fulcrums are the center of the 3rd ventricle or mid-brain, and the sphenobasilar junction (SBJ) located at the superior of the atlas cervical bone. The 3rd ventricle fulcrum reestablishes and maintains health for the nervous system and the SBJ fulcrum reestablishes and maintains health for the skeletal system. All three fulcrums naturally return to a state of balance, “a normal state of action and reaction between two or more parts or organs of the body” (Sutherland, 1990, p. 285). However, each fulcrum may at times be unable to maintain health or return to a state of balanced tension. The process that the body begins to maintain in a state of imbalance is termed an inertial fulcrum.
Michael Kern, a craniosacral therapist, osteopath and naturopath in London, England, states that inertial fulcrums are at the core of diseases and pathology (2002). An inertial fulcrum is a disturbance in the body, attempting to re-establish a sense of balance and a return to vital health. According to Kern, health to the body can be restored when the fulcrum at the disturbance is realigned with the intrinsic health of the body. In order to resolve the out of balance inertial fulcrum, the tension at the fulcrum must be addressed by the cranial therapist. This particular technique is called the point of balanced tension and is found when the cranial therapist locates the point between the tension of the natural fulcrum and the increased tension. This is the point between where the stress in the body is maintaining its focus and where it is felt as a point of no-tension, or stillness. Dr. Magoun referred to this point as the “neutral position,” without push or pull from any direction (1976, p. 99).
Jealous (2000), also shares Magoun’s description of a car being in neutral “available for motion in any direction” (Magoun, 1976, p100). When this point of balanced tension is located by the therapist, health may be restored to the inertial fulcrum and a state of ease occurs where the inertial fulcrum is no longer present. The stressful experiences of inertial fulcrums resolve and the body is able to experience health and increased vitality. The stillness that naturally occurs at this point of balanced tension provides the necessary power to return the body to health (Kern, 2002).
Kern calls this return to health a three step process: (1) attain a felt sense of the body from which the therapist facilitates the patient process, (2) a settling where the state of balanced tension may be accomplished, and (3) integration where the balance and health return and the natural fulcrums are able to maintain health (2002). This return to health is described by Dr. Becker as a process where the therapist allows the “physiological function within the patient” to lead the therapist to a point of balanced tension found at the natural fulcrum (1997, p. 5).
Use of Fulcrums as a Resource
The psychotherapist may need rest, short-breaks, exercise, meditation, socializing, and walks in nature in order to maintain vitality in the therapeutic relationship (Sills & Lown, 2000). These resources may support the psychotherapist by providing enough energy or vitality to sustain his or herself while being present and open to the patient experience (Sills & Lown). Therapeutic fulcrums may provide additional support of resources that a psychotherapist needs in order to maintain vitality in the therapeutic relationship.
The development of psychotherapist presence may be accomplished by having an awareness of the subtle thoughts and feelings (Sills, 2001) and therapeutic fulcrums (Gilchrist, 2000). The development of an awareness of inner thoughts and feelings may promote an anchored, grounded, stable reaction to personal experience, if the awareness clarifies what is getting in the way of settling down into simply being still (Sills, 2001). The fulcrum may be the psychotherapist’s guide to settling down into simply being still and promoting more vitality and a stable presence.
When the therapist seeks the still point of the fulcrum, he or she is attempting to sense the health of the patient (Jealous, 1997). It is the psychotherapist’s challenge to find the stillness at the fulcrum by feeling and hearing (Sills, 2001). The ability to feel and listen for the stillness promotes the therapist’s ability to be open to patient process (Sills). As the psychotherapist is able to be still, the present moment-to-moment experience is filled with vitality and health for the patient (Jealous). Sills suggests this may be called a “sacred space” (p. 82). It may be experienced in the therapeutic relationship. Sills suggests for the therapist to settle into the stillness of the fulcrum, which may create sufficient space for the therapist to experience health thereby supporting the patient in his or her healing process. Sills (2001), and Gilchrist (2006), suggest that fulcrums provide a stable center that may benefit therapeutic relationship by providing a stable presence and awareness that supports patient development and health.
As the psychotherapist is able to sense the still point of the fulcrum, the psychotherapist may sense a feeling of presence or physical stability within his or her body. When the therapist settles into this still point of the fulcrum a clear relationship with the inner thoughts, feelings and health may be experienced by the therapist. According to Sills, the patient’s experience may also start to settle in a fulcrum. The fulcrum which the psychotherapist becomes aware of may also assist the patient in his or her therapy. Sills suggests that this fulcrum grounds the therapeutic process and establishes a sense of stillness and “safe listening space” (2001, p. 82). Fulcrums support the psychotherapist in maintaining a secure sense of the therapeutic process as it occurs in moment-to-moment experience. This process of utilizing fulcrums was created in order to help the psychotherapist negotiate the subtle personal thoughts and feelings of the therapeutic relationship and simultaneously remain aware and open to the patient process (Sills).
A term that may be helpful for the psychotherapist in understanding the concept of the fulcrum and still point is the term “equanimity” (M. Sills, 2000, p. 7). It simply means having enough space for the patient experience to unfold. Maura Sills suggests that the capacity of the psychotherapist to be open and receive, listen and feel what is in the present moment-to-moment experience, includes being open to personal thoughts and feelings at the subtle level. This includes being open to the mind of the patient and cognitive or emotional sources that may appear to be outside of the therapeutic relation, but also have an impact on the present moment-to-moment interaction. Maura Sills reports that the capacity to be open to the full range of experience is necessary for a productive therapeutic process. This process may be maintained by remaining able to receive and to be open or available for the most subtle of thoughts and feelings. When the psychotherapist is able to hold an awareness of the still point associated with the fulcrum, the therapist may be able to perceive at a subtle level of experience. Thus, the therapist may become more vital to the present and open to the full range of patient experience.
Applying Fulcrums in Therapy
    Franklyn Sills and his wife Maura Sills are licensed psychotherapists in the United Kingdom and have developed Core Process Psychotherapy (CPP). Both Maura and Franklyn Sills are Buddhist practitioners and sought to develop a psychotherapy that would include the benefits of meditation in the therapeutic relationship. Franklyn is also educated in the science of osteopathy and has taught craniosacral therapy in England and the United States. In a personal communication Franklyn stated he and Maura formulated a Buddhist influenced psychotherapy form that utilized fulcrums (Sills, June 14, 2006). CPP was developed by Franklyn and Maura Sills to utilize the concept of awareness in mindfulness meditation and apply it to the psychotherapeutic relationship (Sills & Lown, 2000). The concept of the fulcrum, in relationship to health, came from the science of Osteopathy (Sutherland, 1990). Franklyn Sills and Maura Sills appear to be the first to apply the concept of practitioner fulcrums in a psychotherapy model utilizing the osteopathic health maintenance concept of fulcrums.
At this time no other form of psychotherapy other than core process psychotherapy utilizes therapeutic fulcrums as part of the therapist technique to working with patients. Core process psychotherapy is only available to professionals and students in the United Kingdom. Core process psychotherapy is not available in the United States, nor has any published research regarding core process psychotherapy ever explored the possible benefits of lowering stress or preventing burnout. Yet, CPP’s focus is on working with vitality within the therapist-patient relationship by being present to whatever arises in the present moment. Lack of vitality appears to be a factor in determining the level of stress, and impact of burnout. Utilizing therapeutic fulcrums may be an appropriate technique for preventing burnout. Additionally, the exact nature of how therapeutic fulcrums are utilized in core process psychotherapy has not become available. Finally, Maura and Franklyn Sills consider Core Process Psychotherapy to be influenced by the Buddhist traditions.
There are several therapeutic models that assume that health may return to the human body via an intrinsic intelligence and the principle of homeostasis (physiological health maintenance). The name of the founder and his or her therapeutic model are Dr Francine Shapiro (EMDR), Dr Eugene Gendlin (Focusing), Dr Fritz Smith (Zero Balancing), Paul Dennison (Brain Gym), James Durlacher (ACU-Power), John Thie (Touch for Health), Dr Randolph Stone (Polarity Therapy), and Donald Lepore (The Lepore Technique). The application of therapeutic fulcrums may be applied to any of the above listed therapeutic models and may perhaps provide additional support for the therapist.
Sills (2001), suggests that awareness of fulcrums may give the therapist clinical information and help deepen therapeutic presence, a fundamental quality that promotes health and healing (Gilchrist, 2000). The therapist includes an awareness of therapeutic fulcrums which are at three specific anatomical locations. The anatomical locations are located near or along the spine and may access the fulcrums’ vital resources capable of decreasing stress and improving health (Sills, 2001; Engler, 2006).
The therapeutic fulcrums consist of three distinct anatomical locations: (1) external occipital protuberance, (2) mid-torso region of thoracic-10, and (3) the coccyx (Gilchrist, 2000). When the therapist accesses the therapeutic fulcrums by including them in his or her awareness, a process of creating “sacred space” capable of reestablishing or promoting health and decreasing stress and the occurrence of burnout in the therapist may occur (Sills, 2001).
In a personal communication with four health care providers, each offered his or her opinion about the experience of becoming aware of the therapeutic fulcrums. Mark Craig, a United Kingdom psychotherapist, stated fulcrums provide a way of being present with patient work that supports the therapeutic relationship and provides a center (point of neutrality), for the patient experience (personal communication, December 12, 2006). Mark Craig may be suggesting that fulcrums assist the therapist in providing a sense of presence and stability in the therapeutic relationship.
According to Gilchrist (2000), therapeutic fulcrums support the therapist and patient therapeutic relationship and benefit both. Gilchrist suggests that therapeutic fulcrums help therapists become more aware of patient physical location and orient the therapist to a more-at-ease physical relocation creating more space between the therapist and patient. Suellen Trumbore-Cheney a registered nurse and holistic therapist reported that therapeutic fulcrums are what allow the “sacred space” to occur (personal communication, July 25, 2006). This may indicate that when a therapist maintains an awareness of therapeutic fulcrums an optimal therapeutic relationship that benefits each participant may be created.
Luisa Stahl-Coppinger an ophthalmic technologist and surgery assistant stated at first when she included an awareness of the therapeutic fulcrums in her work she became aware of a subtle altered state of mind, followed by an awareness of her breath, and a sudden realization that the physical sensations of pain in the upper thoracic back and arms was no longer present (personal communication, January 17, 2007). Luisa also noticed that there was a sense of stability or greater awareness of the ground at her feet and she became more generally aware of her physical body, and correction of posture (personal communication, March 20, 2007).
This appears to indicate and concur with Gilchrist (2006), and Sills (2001), that therapeutic fulcrums promote a centering point for the therapeutic relationship which may stabilize the physical body and improve vitality. Wendy Mathews, psychotherapist and cranial therapist states that the fulcrums may provide a neutral for patient experience and helps the therapist provide enough space for the therapeutic relationship to unfold and promote health in the therapist and patient (personal communication, January 31, 2007).

Introduction to Action Project Description                        
    This action research will measure the degree of psychotherapist burnout prior to the teaching of an easy to use in-session technique, called therapeutic fulcrums. The application of therapeutic fulcrums suggests a simple meditative-like technique that may reduce stress in the therapeutic relationship and reduce the probability of burnout symptoms. Following the presentation of the therapeutic fulcrum technique, participants will be given an opportunity to examine the effect by role playing and discuss the possible benefits with each other in a qualitative focus group. The workshop presentation will end with a post measure of burnout symptoms.
A semi-structured interview will be given before the pretest (Appendix A), to determine eligibility for the project. Pretests and post-tests will be given to all participants. Baseline and post intervention measures on both control and experimental groups would be taken. The Self-Perception and Relationship Tool (S-PRT; Atkinson, Wishart, Wasil, & Robinson, 2004), would be given to measure perceptions, preferences and attitudes in real life experiences of care-givers. The Maslach Burnout Inventory (MBI), scale and modified Maslach Burnout Inventory for therapists (MBI-T), will be given to measure emotional exhaustion, depersonalization and personal accomplishment. In a post test phase participants will be asked a list of questions regarding what effects the therapeutic fulcrums had on clinical practice (Appendix B).
The participants of this study will be recruited from the Wellness Center located in Ludlow, Vermont. Enrollment in the program will be open to all psychotherapists, counselors, social workers and psychologists within the Northeast states including Vermont, New Hampshire, Massachusetts, Maine, Connecticut and New York. The Director of the Wellness Center, Suellen Trumbore-Cheney, has agreed upon having the study and verbal agreement has been made. A proposal for the therapeutic fulcrum study will be submitted to Suellen Trumbore-Cheney (Appendix C).
Possible participants for this study will be contacted via email address retrieved from association websites for licensed psychotherapists in the Northeast States (Appendix D). The association websites that will be contacted are The Associated Psychotherapists of Vermont, Vermont Mental Health Counselors Association, Vermont Addictions Professionals Association, New Hampshire Mental Health Counselors Association, Massachusetts Mental Health Counselors Association, Connecticut Counseling Association, New York Mental Health Counselors Association, and Maine Clinical Counselor Association.
Additional announcements of the study will be provided through posters that provide sign-up opportunity for Dartmouth-Hitchcock Medical Center (DHMC), employees and will also be posted at the Ludlow, Vermont Wellness Center (Appendix E). A presentation describing the study will be made at the Ludlow, Vermont Wellness Center, and a poster announcing the presentation will be posted at DHMC, and the Wellness Center (Appendix F). Information provided at the talks will include length of therapeutic fulcrum study eight hour class. The date and time of possible future classes will be sent at the later announcements. A brief description of the possible benefits to therapists that apply therapeutic fulcrums, body scan, and breath awareness will be mentioned along with an announcement that additional information will be made available to those individuals interested in the program.
Ethical considerations for the participants in the study include the signing of the informed consent (Appendix G). Confidentiality will be requested and all participants must sign an informed consent before beginning the program (Appendix G). Confidentiality for all participants will be assured by the researcher(s) of the therapeutic fulcrum study. Confidentiality will be discussed at the beginning of each two hour segment throughout the day of class.
Additional ethical considerations will include an announcement of possible benefits to the participants of the study. The possible benefits may be a decrease in stress, and related physical symptoms such as fewer symptoms associated with burnout, increase in vitality, and an increase in social contacts. Possible risks were also noted such as muscle cramping, dizziness, intrusive thoughts and fear of losing control. Individual consultation will be provided by the researcher if any participant asks for assistance an appropriate referral will be offered if necessary.
It will also be necessary for each participant to complete a health assessment (Appendix, K), prior to the beginning of the first day of class. All interested participants must meet with the researcher prior to the class and complete the health survey. The researcher will review the health survey for individuals that do not have major mental illness, active chemical dependency issues or suicidal tendencies. All participants will be contacted and results from the health survey will be discussed. The screened participants that meet the required qualifications will be notified by email (Appendix H). All pre and post test interviews and evaluations will be designated with coded numbers and will remain in a secure location.  Participants will be offered an opportunity to receive feedback regarding individual scores and group means.
    Meditation Research Procedures
The two most widely used measures of inventories are the Burnout Measure (BM), previously named the Tedium scale (Pines & Aronson, 1988), and Maslach Burnout Inventory (MBI: Mashlach and Jackson, 1986). Professional healthcare providers such as counselors, teachers, nurses and policemen have been sampled with burnout measures. The MBI appears to be the most frequently used tool to measure burnout (Glass & McKnight, 1996).
Green and Walker’s (1988), research regarding the MBI validity has been documented by Malsach (1976), Pines and Kafry (1978), Maslach and Jackson (1979, 1981), and Rafferty, Lemkav, Purdy, and Rudisill (1986). Burke and Richardson’s (1993), research has documented the MBI as a reliable three sub-scale measures device. Maslach and Jackson (1986), reported alphas for the three sub-scales to measure .71 to .90 for samples in a study of over 11,000 healthcare professionals. The BM is the second most widely used measure and in over 4000 cases (Pines et al., 1981), has alpha measures of sub-scales  typically at .90 (Glass & McKnight). The BM has similar features compared to the MBI for it also utilizes three sub-scales, however factor analysis studies do not distinguish more than one dimension in the measure (Justice, Gold & Klein, 1981).
The first evaluation tool used in this research project will be the Maslach Burnout Inventory, Second Edition (Maslach & Jackson, 1986). The MBI is a 22 item scale and each item consists of a 7 point frequency scale (Linehan, Cochran, Mar, Levensky & Comtois, 2000; Jaltuch, 1997). The scale is an attempt to measure participants’ feelings toward work using a zero to represent “never” and six to represent “daily” (Linehan et al., 2000; Jalltuch, 1997). The MBI has three subscales: Emotional Exhaustion (EE), which has nine items where higher scores equal greater EE; Depersonalization (DP), which has five items where high scores equal greater DP; and Personal Accomplishment (PA), which has eight items where lower scores equal less PA (Linehan).
The second measurement will be the MBI-Therapist Version (MBI-T), which was modified by Linehan et al. (2000). The MBI-T is also a 22 item scale with a 7 point frequency scale. An example from each EE, DP, and PA sub-scale item respectfully is, I feel emotionally drained from working with my clients patients, I feel I treat some of my patients as if they were impersonal objects, I can easily understand how my patients feel about things (Linehan et al.)
The third measurement of this action research will be the Self-Perception and Relationships tool (S-PRT), which may assess a patient’s experience of health (Atkinson et al., 2004). This qualitative measure is a subjective health related quality of life (HRQL) tool for understanding the patient’s experience, perspective and goals (Gordon & Paci, 1996; Joos, Hickam, Gordon & Baker, 1996). This instrument is intended to measure six areas: (1) physical well being, (2) mental emotional well being, (3) interpersonal receptiveness, (4) interpersonal contribution, (5) spiritual receptiveness, and (6) spiritual orientation (Atkinson, Wishart, Wasil & Robertson, 2004).
Examples of questions for the patient regarding each measure are respectively: (1) “Within my illness experience, I  physically feel I am ... ,” (2) “Within my illness experience I feel I am ...,” (3) “My relationships help me feel I am ...,” (4) “Towards those who are emotionally close to me I feel I am ...,” (5) “Universal beliefs and principles or a divine presence help me feel I am ...,” and (6) “Towards universal beliefs and principles or a divine presence I feel I am ...,” (Atkinson et al., 2004, p. 4).  The HRQL is a qualitative and quantitative assessment from the perspective of the patient (Brochs, 1997; Coyle & Williams, 2000). The S-PRT appears to be a useful measure for understanding the health care professional subjective experience.
The fourth measure for this action project is the MOS SF-36 Version 2. The MOS SF-36 is a self-perceived health status HRQL measure and is widely used (Ware & Shelbourne, 1992; McHorney et al. 1993; McHorney, Ware & Sherbourne, 1994). The SF-36 has 36 items that measure eight domains of health: (1) physical functioning, (2) physical health problems that limit physical role (3) pain of the body, (4) health in general, (5) vitality specifically fatigue or energy, (6) social function, (7) emotion problems that limit emotional role, and (8) psychological distress or well being (Ware, Snow, Kosinski, & Gandek, 1993, 2000).
Qualitative research
    To assess participant experience from this action plan the facilitator will conduct a focus group during the seventh hour of the eight hour workshop. Patton’s (2002), research has shown that focus group research is a qualitative data gathering method for obtaining a variety of views on experience. Christopher (2000), reported that focus groups have also shown to be a useful tool in gathering data. Morgan (1988), has shown that focus groups utilize group interaction to produce data, but also to gain insight that would not be available without the interaction of the group. This focus group may allow the participants an opportunity to reflect upon the intervention of therapeutic fulcrums and how this may reduce stress and prevent burnout.
A moderator’s guide was developed based upon Patton (2002), and Morgan and Kruger (1998,) guide on focus group instructional series. Patton’s (2002), Qualitative Research and Evaluation Methods guided the process of framing how the facilitator would conduct the group. Morgan and Kruger’s (1998), guide provided probing questions and group control techniques.
The facilitation guide would list the purpose of the group, probing ideas and discussion questions. An example of these facilitator questions for the participants are: “What rules do we need to have a productive discussion?” An example of the participants’ rules might be listening to others’ opinions, there are no right or wrong answers, and keep confidentiality. These rules for focus group research are similar to research by Morgan (1998), and Templeton (1994).
The Project
The length of the proposed project is four two hour seminars. The first workshop agenda will be for introducing all participants and the idea of the body scan and utilizing the breath. After completion of the pretest measures, the control group will begin the first two hours of the eight-hour study. The wait list participants will begin the study once the control group is done. The remaining time of the first two-hour segment, participants will be devoted to getting acquainted through brief introductions of all participants. Next the participants will be introduced to a relaxation technique for stress reduction and the development of body awareness. In the following sections, participants will explore a breathing and visualization technique for maintaining attention and awareness in the therapeutic relationship. According to Sills (2001), this technique may help inform the participants through body awareness of personal boundaries between practitioner and patient. This personal boundary awareness may in turn lead to an increase of vitality and probability of preventing burnout.
Franklyn Sills’ view of therapy is that developing presence is at the heart of the therapeutic relationship. Sills’ opinion is that through developing therapeutic presence vitality may flow, and it is also essential to be present in order to simply listen. In this particular model of treatment, therapists learn to listen deeply to the human condition and its intrinsic health. The following procedure appears to promote an anchor or ground for the practitioner-therapist. This may be necessary in order to gain a felt sense of what being present feels-like. It is suggested that the ability to be present may be developed and refined whenever in a therapeutic relationship. Presence has a soft quality to it. Yet it also has vitality. Also the attention of the practitioner is not narrowed or forced. It takes in the whole and notices the particular. It is as if the therapist is witnessing the presence of a newborn baby, and the therapist softly meets the whole of the baby with care and compassion. Finally it is suggested that the therapist also notice the particular, the movements, the expressions, and the sounds.
In order to promote relaxation and awareness in the body a technique of utilizing the breath and muscle relaxation is suggested. First, begin breathing from the belly by sitting in a straight, upright position. Then close your eyes and slowly inhale through your nose, and fill your lungs from the bottom up to the top, using the muscles of the stomach to pull down the lower lobe of the lungs. You may do this by exaggerating the extension of the stomach (if necessary stick that gut out). Once the participants have inhaled fully, each is suggested to lift the shoulders to fill the very top portion of your lungs. Finally, hold this breath for a count of two, then, slowly exhale through your mouth, and repeat this slowly for one or two minutes.
Sills’ (2001), research suggests to slowly approach this learning process of becoming more aware of the body. This in turn may help slow down the mind and body. Each therapist may notice that the body may begin to tingle, and feel refreshed and clear. Deep breathing may improve the flow of oxygen to the brain, and help to remove the excess carbon dioxide. This may help the body and mind be clear and more aware of the body and its immediate environment.
The first step in the practice of presence is for the therapist to become aware of his or her body and immediate surroundings (within hands reach). This may seem obvious, but  therapists may not take the time to become aware of innermost thoughts and feelings and the possible outer manifestations. The development of presence is really a development of the ability to know what gets in the way of just effortlessly allowing thoughts and feelings too simply be felt. This perception of the sense of self must be rooted in the body and its sensations in order to develop the skill of feeling body presence, subtle thoughts, feelings and the awareness of the patient presence.
The following process may help develop body awareness in the therapist. The breath is always present. Therefore it may be a useful reference point from which to explore being present to moment-to-moment experience. In the tradition of Tibetan Buddhism, there is a saying that if a person experiences life from the breath insight and peace will come to the practitioner (Sills, 2001).
Sit comfortably up-right, and simply become aware of your breathing. Follow the breath in the body and out of the body. Be aware of the sensation of breathing and simply follow this sense in and out. This first step helps direct attention into the body and its sensations. It may also help to initially create an anchor for your awareness.
Participants are suggested to notice the quality of his or her breath and ask his or her self several questions. Is it easier to inhale or exhale? Is one phase fuller than the other? As each participant to explore how far his or her awareness goes into the body? Participants are to inhale and allow the awareness to follow the movement of each breath right down into the lower extremities? Are any areas of body not available to be accessed by attention?
Next each participant is to follow his or her breath in one more time, and then just effortlessly allow the attention to be within the body without following the breath. Let the breath be the observer. This observer experience of allowing the breath to observe allows the participant to be neutral. The practitioner may be able to describe his or her inner experience as the observer, and shift the attention to the quality of sensation in your body. The participants are to ask his or her self are there any areas of pain or distress? Are there any emotional tones or feelings?
After holding this awareness of sensation for a minute let that go too. Now each participant is to see if he or she can simply sit, and noticing anything that arises. Each participant may notice feeling tones, thoughts, images, sounds, and so on. Is there any relationship to these feeling tones, thoughts or images? Can participants notice whatever arises and let it pass away? Do participants get caught up in it unable to let it pass? Can participants be like a vast sky of awareness? Can participants let whatever comes within the awareness pass like clouds moving through it? Is there the space to simply listen and notice what arises within the awareness?
Participants are suggested to next listen and let his or her awareness include the body, and the surrounding space around it. Soften the attention and see if the mind settles into an awareness of listening. Effortlessly allow the mind to listen. It is about allowing and letting go. Each participant is to ask his or her self what is noticed? Does the mind become still? Is there more clarity?
If the mind continues to experience images, feelings, the participant is to simply notice the breath and effortlessly allow the awareness to settle. Then once again widen the awareness and listen to see if the mind settles naturally into a still yet aware state. This exercise may be practiced as required during the day in order to let the potential for inner awareness and space become part of your life.
Presence may be the foundation for exploring relationship. Therapeutic presence requires attention and ability to be direct and appropriate to the patient experience. In this context the therapist may be a mirror of the patient experience. Stillness may help the therapist in accessing the patient experience and lowering personal stress. This may include having a still presence in response to the patient process. Stillness may be the foundation of our human condition. Therapeutic access to stillness may be a technique that is helpful in listening to patient experience. When the therapist is listening from the perspective of stillness, he or she may perceive the health that is intrinsic.
A therapist’s personal needs and desires may interfere with the therapeutic relationship. Therefore, it may be helpful for the practitioner to approach the patient from a neutral. Neutral here is defined as not needing, or expecting anything, and developed by the therapist by listening for the stillness within the therapeutic relationship.
In order to be able to listen to the most subtle of personal and patient experience the practitioner may need to remain aware of having a clear sense of space or boundary between the therapist and the patient process. It is suggested that each therapist have a clear intention and maintain clear awareness of his or her physical presence in order to maintain a subtle awareness between the therapist and the patient. If the therapist does not have an intention of appropriate physical or emotional space, he or she may not be able to remain vital and clear during the therapeutic relationship. The therapeutic relationship may become unclear, and the therapist may not be aware of this experience until fatigue is felt. The following exercise may help the therapist remain clear and vital in the therapeutic relationship by becoming aware of the subtle therapeutic presence and patient boundaries.
The next exercise may help the therapist become more aware of personal presence and that in turn may provide the therapist with a clear sense of the therapeutic relationship and specifically what is the most appropriate distance for maintaining vitality.
1.    Once again, simply become aware of the breath and follow the inhalation and exhalation in and out and notice how the body (chest cavity, digestive organs, and ribs), responds to each breath taken. Stay with this for a minute.
2.    Have the therapists notice what if anything takes his or her attention away from the breath. It may be thoughts, imagery, fantasy, feelings, sound, or other body sensations. If there is difficulty remaining aware of the breath gently acknowledge what is perceived, and return to the attending to the breath. Stay with this process for a minute and begin to include equal awareness to the breath, and what moves the attention away from the breath.            
3). Next, direct each therapist to notice coming back to the breath, and being taken away from the breath, and  what takes him or her away and the intention to return. Therapists may notice what thoughts lead away from the breath, or images, sensations, and external sounds. Suggest to each therapist to effortlessly allow the intention to return to the breath. As each therapist moves toward the breath again, see if each therapist can find a neutral between the breath and noticing the thoughts.
        Between breathing and noticing therapist may settle into a place of balance. Notice a possible felt sense of staying with the breath, and being drawn away from it, and notice a neutral point between the two states. This is a point or state of balance between the coming and going of awareness and intention. This is a place of balance between the two. Continue to experiment with this, and notice that this point of balance has a sense of space within your mind and felt sense within the physical body. Is it possible to rest in the space of relative balance and ease within the mind and body?
        This may be considered a still center, and may be a place from which each therapist may experience vitality before entering a therapeutic relationship. This may give each therapist a clear felt sense of the still point that is associated with the therapeutic fulcrums. The therapeutic fulcrum each therapist settles into may ground the therapist, and generates a still, safe listening space. The following section may help clarify and establish the therapeutic fulcrum process. It is meant to help each therapist understand the subtle thoughts and feelings of the psychotherapeutic relationship and support the therapist in creating a sacred space that may prevent burnout.
        Before the introduction to therapeutic fulcrums begins, notice the internal body felt sense. Just become aware of the body, and effortlessly allow the intention to be inside the body. Follow the breath from the nose or mouth down into the body as far as possible. Follow each breath into the body space and notice the felt sense before entering into the therapeutic relationship.
Section Two (Hour Three and Four)
        This action research project will detail how the therapeutic fulcrums will be taught to psychotherapists. This project will be presented in the second two-hour workshop. The first step is for each participant to inwardly focus upon the felt sense of the body.  It is essential that each participant check in on this aspect when beginning the therapeutic relationship. The intention is to be or have awareness of the inner body space or feeling tone.  This is accomplished by following the breath into the body and the body’s sensations.  Start this body scan by inhaling from the body up from the feet to the legs into the abdomen.  The intention is to have a sense that present feeling may be experienced and interpreted from within the body. Ask what is felt now? What may get in the way of the therapist-patient relationship? Can this awareness be held?
        When beginning to sit with the patient open the awareness to include the patient’s comfort level and adjust the eye focus and attention either away or close until there is a sense of meeting and contact.  This may be enhanced by listening to the whole person, the body and the sense of area that exists between the therapist and patient.  Effortlessly allow this concept of paying attention to the whole person and therapist-patient space that exists near and around the patient to be part of the therapist-patient relationship.  This process will be clearer after the next step is explored.  The fulcrums that will be introduced may help develop a clear sense of personal space and presence and may reduce stress in the therapist-patient relationship.
First Fulcrum
        Chia, Mantak and Chia, M. (1990), suggest to inwardly-smile in order to gain awareness of the inner body physiology and felt sense. Chia, Mantak and Chia, M. suggest smile-inwardly toward the eyes and smile toward the rear of the cranium, down the vertebral column. Smile inwardly through each of the seven cervical vertebrae, the twelve thoracic vertebrae, the five lumbar vertebrae, through the pelvis to the coccyx. A look at the vertebral column in anatomy books may be helpful (Appendix K).
        After each therapist has a felt sense of the coccyx have each therapist smile inwardly to the earth or floor directly below the feet. The distal spine or coccyx and visualization of a vector directly to the earth is the first fulcrum (Appendix K). Establishing this point as a fulcrum may help the therapist to feel solid on the ground and may also develop presence in the therapeutic relationship. Verify that each participant is able to have a felt sense of the lower portion of the body and the connection to the earth and then move on to present the next fulcrum.
Second Fulcrum
        Begin with Chia, Mantak and Chia, M. (1990), suggestion to inwardly smile to the eyes, and smile to the rear of the cranium toward the rear of the head at the external occipital protuberance (EOP). This is located just above the occipital notch and may be felt with the hand as a slight bump that extends posterior along the occipital ridge. It is centrally located approximately one inch above the posterior superior neck. Smile toward the EOP and smile toward the internal occipital protuberance (IOP). The IOP is located at the confluence of sinuses.
        A point anterior to the IOP is called the straight sinus and has been named Sutherland’s fulcrum after William Garner Sutherland, D.O.  Dr. Sutherland was the first doctor in the science of osteopathic medicine to specialize in treating the cranium. A look at anatomy books may be helpful in visualizing this fulcrum, the EOP, IOP, and straight sinus (Appendix L).
        Once again smile toward the rear of the cranium toward the EOP and extend a vector to the floor behind the position of the body’s feet (Appendix L). The second fulcrum may help the therapist develop a still quiet center, and become aware of the space between the therapists and patient. The therapists are suggested to widen his or her awareness to include this fulcrum point extending behind the feet and just touching the floor or surface of the ground. This point and extension from the EOP to the ground is not meant to be firmly attached to the ground. Just notice how settling into the body with awareness of this fulcrum becomes a reference point to return to for added clarity and awareness of the physical body presence.
        Confirm that each therapist has a felt sense of the second fulcrum. Now that the second fulcrum has been experienced return to the awareness of the first therapeutic fulcrum by smiling inward and sense the coccyx to the floor or earth under the feet. Once this has been re-established, include each fulcrum (coccyx and EOP) in the awareness by settling the body into both fulcrums, allowing a sense of each to come into the awareness. Suggest to each participant to inwardly smile, and effortlessly allow this feeling of the therapeutic fulcrums to be experienced for a minute.
Third Fulcrum
        The last fulcrum is located at thoracic ten (T-10). Another name for T-10 is dorsal 10. T-10 is the tenth thoracic vertebra and is located just proximal from the kidneys, adrenal glands and abdominal diaphragm. For help in visualizing T-10 review anatomy books (Appendix N).
        Once again as Chia, Mantak and Chia, M. (1990), suggest smile into the eyes, and inwardly smile into the vertebral column beginning with each of the seven cervical vertebrae, and continue to inwardly smile down each of the 12 thoracic vertebrae, and effortlessly allow the awareness to settle upon T-10. As the awareness senses T-10, notice how the breath may change. This area of T-10 is central to the breath (Stone, 1986), and having an awareness of T-10 may provide an inner fulcrum for maintaining vital breath. Sills (2001), suggests bringing attention to T-10, which may also enhance the physical awareness and felt presence of the body.
        A student of Dr. Sutherland, Dr. Randolph Stone, identified T-10 as an activation point for the breath (Stone, 1986). Having an awareness of T-10 may promote breathing during stressful encounters with clients (Goleman, 2003). Dr. Bernard Aschner has also suggested that this point is a vital support for maintaining positive mental health (Stone, 1986). Once again, turn to anatomy books for help in visualizing this point (Appendix N).
        Now return to fulcrum one, by inwardly smiling to the connection from the coccyx to the earth below the feet and fulcrum two, the connection from the EOP to the contact point behind the feet. Once a felt sense of the first two fulcrums is experienced by the participants, include the final fulcrum at T-10, and allow the body to settle into all three fulcrums for 1 minute. Suggest to each participant to notice any sense of presence, breath change or physical body awareness as the body settles into the three therapeutic fulcrums.
Third section: the Practice Session (Hour Five & Six)
        The third section or hour 5 and 6 of the study will begin by taking 15 minutes to inhale up the body from feet to torso. This will help each participant to recall a felt sense of the body. Next, the participants will take 15 minutes to settle into the three therapeutic fulcrums. For the remaining time of this segment (90 minutes), participants will form groups of three, and take turns being the therapist, patient, and the observer. This will give each therapist 30 minutes in each role, and practice utilizing the therapeutic fulcrums as the patient and observer. The therapist will practice utilizing the fulcrums while taking an assessment of the client. Each participant will practice being a client, therapist and observer, and practice utilizing the therapeutic fulcrums. This process will include utilization of assessment forms by each role playing client (Appendix P).
Final Two Hour Segment
        The fourth and final two hour seminar will begin with a focus group that will explore the experience of utilizing therapeutic fulcrums in the triads.  A list of questions for the group participants will guide the group process toward a productive discussion. The focus group will be presented with questions in order to elicit participant experience.  The proposed questions are why did each therapist take the workshop, what is the first image that comes to mind when each participant reflects upon the workshop, what did each participant like about the workshop, what about the class interested each participant the least, what are the strengths and weaknesses of the therapeutic fulcrum study, and finally are there any other comments? After the end of the focus group, it is expected that each participant will complete the post test survey and depart for the day.
    Focus Group Analysis
        The focus group will be tape recorded and notes regarding the group session will be recorded directly after the end of the group. The tape will be transcribed by a professional at Dartmouth Hitchcock Medical Center. A review of the tape exploring inductive content analysis will be utilized to identify themes in the data (Patton, 2002; Strauss & Corbin, 1990). The transcribed data will be reviewed in order to identify similar participant experiences. The transcribed data will be grouped into themes, and final results will be determined.    
Issues for Consideration
        There are five issues which may affect the implementation of the plan. First, confidentiality must be adhered to. Participants will be required to sign a confidentiality statement at the beginning of the course and will be reminded at the beginning of the focus group to maintain confidentiality. Second, participant issues may arise during the workshop. The facilitator must attend to any participant distress and make appropriate referral if participants do not have a therapist or professional guidance for personal issues. Third, focus group size will be limited to twelve and therefore if eligible participant numbers are greater than twelve, additional facilitators or additional studies may be considered.
        Focus groups may need co-leaders to function best, and provide additional support for the participants. Additional co-leaders may be needed to function as reviewers of the proposed focus group themes and review findings before reaching a final conclusion of the data. Four, as Jon Kabat-Zinn suggests, it is essential for the facilitator to be aware of whatever is occurring in the present moment (Jaltuch, 1997).
        Facilitators must respond to each participant interaction with clarity in order to emphasize being clear with what is known and unknown. This model of interaction between facilitator and participant demonstrates an ability to deal with stress without feeling the need to be viewed as an expert (Walsh & Vaughan, 1991). Sitting in meditation allows the participants to observe interactions with the facilitator and experience a clear open response to other participants as the interaction unfolds in the moment. Jon Kabat-Zinn suggests that facilitators must have a practice of meditation prior to becoming a facilitator in order to role model in-the-moment interactions that are clear and calm, firmly grounded in the practice of mindfulness (Jaltuch, 1997). Thus focus group size limitation will determine how many participants may take part in the study. If eligible numbers are higher than twelve, additional co-facilitators or future studies may be considered.
        The fifth issue is time availability. Therapists tend to lead busy lives and may not take the time to take care of themselves by slowing down to sit for meditation. Meditating psychotherapists may find the study appealing. However, in order to change the health of the next generation of psychotherapist, an in-class course at a graduate school would be recommended. Having a course for psychotherapist self-care with meditation would be helpful. Christopher et al. (2004) have demonstrated that MBSR presented to students may lead to burnout prevention.
        The sixth and final issue is that participants will learn therapeutic fulcrums and begin to utilize this technique upon returning to work. Perhaps a follow-up workshop could be planned for the future to address concerns of participants. Specifically, how the fulcrums helped in personal or professional interactions, and if applying therapeutic fulcrums caused any distractions. The follow up could be announced with emails or suggestions taken at the end of the workshop for possible future workshop dates.
Implementation of Action Plan
        Participants will be guided through the process of scanning the body from the feet up to the head by utilizing the breath. Participants will have access to anatomy pictures that detail the specific location of the fulcrum points and other more general areas of the anatomy such as the feet, legs and torso. The intent will be to gain some physical sense of the body and gain awareness of the body sensations as the breath is consciously utilized as a method for gaining body awareness.
        The second of four workshops will explore the application of therapeutic fulcrums after all participants have gained body awareness by the body scan method. All three fulcrums will be taught during this two hour workshop. Participants will be encouraged to begin each day of work by settling into the fulcrums and end the day of work by reconnecting with the felt sense of the body being through body scan, breathing and applying the therapeutic fulcrums technique.
        Once therapeutic fulcrums are learned by the psychotherapist, the therapist simply includes an awareness of the therapeutic fulcrum to experience the benefit (Sills, 2001, 2004; Gilchrist, 2000, 2006). No additional time either before or after the clinical time with the patient is required for therapeutic fulcrums to benefit the therapist. The therapist need only hold the awareness of the fulcrums to experience less stress and possibly less symptoms of burnout (Sills, 2001). Unlike other forms or meditative techniques, therapeutic fulcrums do not require additional time to practice and therefore may be utilized by psychotherapists and helpful for the community in preventing the loss of the therapist due to burnout.
        The action project will consist of teaching the application of therapeutic fulcrums to meditating and non-meditating therapists (social workers, substance abuse counselors, psychotherapists, and psychologists) in the New England region. This proposal to examine the effects of therapeutic fulcrums will use a randomized control study group. The group will consist of a wait-list control group and an experimental group. The experimental group will be taught how to utilize therapeutic fulcrums in four two-hour segments during the course of one eight hour day workshop. The control group will receive the training after the experimental group has completed the course.

Chapter Four
Means of Evaluation
        The proposed evaluation method is a variation of that utilized by Shapiro et al. (2005). The therapeutic fulcrum study will use a randomized control study design that utilizes a 2 (experimental vs. wait-list control group), x 2 (baseline, post-treatment) ANOVA research design. This design will produce a between-group comparison condition. Research design for meditation studies suggest, also including a qualitative component which will be included at the end of the study. Participants will be randomly assigned to the 8 hour therapeutic fulcrum study or wait-list control group. The control group will receive an identical therapeutic fulcrum study following the experimental group completion of the study.
        Participants will be licensed social workers, substance abuse counselors, clinical mental health counselors, or psychologists from the northeast region. A pretest interview will obtain current mental, physical health status, and confirm no current substance abuse problems or current suicidal ideation. Also, participants need to be currently licensed and working as professional healthcare providers with an interest in reducing stress, decreasing burnout symptoms and improving overall wellness. Additionally, participants must be at least eighteen years old and speak English. Eighteen to twenty-four respondents will be necessary to begin the study. The respondents will complete the intake assessment and half will be randomly selected for the control group, and the remaining half will be assigned to the experimental group.
        Outcomes are determined from two different perspectives: (1) pre and post action project psychometric testing, and (2) review of information taped during the focus group. The Maslach Burnout Inventory (MBI) utilizes three sub-scales that measure Emotional Exhaustion (EE), Depersonalization (DP), and Personal Accomplishment (PA), and Maslach Burnout Inventory-Therapist Version (MBI-T) will be utilized as a measure of burnout in the participants. The MOS SF-36 will be used to measure vitality of the physical body and fatigue of the mind. Scores of lower EE and DP would indicate improvement. Higher PA and vitality scores would also indicate improvement. The results would be determined by comparing pre and post test scores among the experimental and control wait-list group. If the symptoms of burnout have decreased, participants’ EE and DP would be lower, and PA and vitality on the MOS SF-36 scores would be higher.
Evaluation Design
        In addition to the quantitative findings, one qualitative data will be obtained in the focus group ending the session. The qualitative data will be recorded at the focus group using similar open ended questions suggested by Christopher et al. (2006); Morgan (1998), and Templeton (1994). The questions were why did each participant take the therapeutic fulcrum study, what is the first thing that comes to mind when each participant considers this seminar, what about the class interests each participant the most, what about the class interests each participant the least, what are the strengths and weaknesses of the therapeutic fulcrum study, and are there any other comments?
        The tape recorded focus group data would be transcribed and the content analyzed according to primary themes (Patton, 2002; Strauss & Corbin, 1990). Themes would be identified and grouped. Additional review of data by the facilitator(s) may be required so that themes would be discussed until agreement on all themes was achieved. Co-researchers would then co-write the results section.
        Christopher et al.’s (2006), MBSR research on preventing burnout in counseling students found that mind-body self care techniques had a significant impact on personal and professional interactions with friends and colleagues. It appears that participants may experience greater awareness, ability to focus, and be present to whatever experience is in the moment (Kabat-Zinn, 1993). The acquired abilities of being better able to emotionally and mentally deal with stress in students has been found by other researchers (Astin, 1997; Bruce, et al., 2002; Shapiro et al., 1998).
        The therapeutic fulcrum series would produce quantitative data from pre and post tests, and qualitative themes from the focus group. The exact nature of what these responses may be can only be speculated. However, a few personal opinions have been obtained from psychotherapists who currently utilize therapeutic fulcrums.
        Comments from Franklyn Sills, the co-author of a psychotherapeutic process that includes therapeutic fulcrums was obtained. Franklyn Sills reported that a handout on therapeutic fulcrums was in the process of being revised. A copy of this revised, previously unpublished handout would be emailed to this writer, Richard Crandall, but at this time has not been received.
        In a second email, Franklyn Sills wrote “I am also a psychotherapist (licensed in the United Kingdom), and have helped formulate a Buddhist influenced psychotherapy along with my wife, Maura Sills. It uses practitioner fulcrums in a particular way and is awareness based ...” (Personal Communication, June 14, 2006).        
Explanation of Evaluation Method/Design
        Qualitative and quantitative data may be combined and evaluated in the same study (Patton, 2002). Qualitative methods promote a study that has depth, detail, and is open without being confined to predetermined categories of quantitative design (Patton).  Quantitative research utilizes standardized measures to determine specific experience of people, and assign a quantity to each category (Patton).
        Caspi and Burleson (2005), suggest that future meditation studies use a mixed quantitative-qualitative method. This would allow participants to reflect upon the study experience and obtain information regarding any change that may have occurred as a direct result of the study (Caspi and Burleson). This method offers participants in the study an opportunity to rate the quality of the meditation experience, and to help identify which aspect of the study helped the most.
        Jaltuch (1997), acknowledges that the stress of work affects healthcare providers, and can be experienced as burnout. Jaltuch completed a study of hospital employees at a wellness center. The program closely followed the Mindfulness-Based Stress Reduction (MBSR), offered at the University of Massachusetts. The Jaltuch study utilized a combination quantitative-qualitative research design. Results from the study indicated significant improvement in the Maslach Burnout Inventory (MBI) sub-scale of Depersonalization. Therefore, the MBSR program appears to be effective in treating stress and burnout in care-givers in the workplace.
        No other study until Shapiro (2005), examined the effects of MBSR on the healthcare professional actively involved in providing care. The Shapiro study utilized a randomized trial methodology that implemented a 2x2 study design. This pilot study showed a decrease in job burnout 10% to 4% and decreased distress 23% to 11%. Results from the Shapiro et al. research, appears to show benefits of meditation-based intervention for healthcare professionals. In addition to the quantitative data, the qualitative responses suggest that MBSR appears to be beneficial for healthcare professionals.
        The third and final research that guided this action research on therapeutic fulcrums is Christopher et al. (2006). Teaching self-care through mindfulness practices research by Christopher et al offered a method of preventing burnout to student counselors. Christopher et al. chose a qualitative data gathering method utilizing a focus group to gain a variety of perspectives (Patton, 2002), a useful tool in gathering data from students (Christopher, 2000), and allowing participants to learn from each other (Morgan, 1988). The Christopher et al. report results suggest that a course at the college or graduate level for therapists is significant in the life of students for it improves personal ability to perform within clinical environments.











        Freudenberger (1974, 1975), and Maslach (1976), were the first to define burnout as a syndrome. Burnout appears to be a syndrome of depersonalization, emotional exhaustion, and a feeling of reduced personal accomplishment (Shapiro et al. 2005). Research has shown that burnout may be an emotional response to persistent stress that progressively diminishes an individual’s innate vital energy (Shiran, 1984). Coping with stress and burnout may be a significant factor in the career of psychotherapists (Christopher et al. 2006).
        In order to prevent burnout Grosch (1994), recommends that therapists utilize self examination and acceptance of thoughts or feelings. Suran and Sheridan (1985), suggest that burnout may be the result of personal and professional conflicts and tasks that are unresolved. According to Farber (1983), cognitive assessment of stressors may play a central role in the development of stress. Therefore, if the therapist does not address current stressors, he or she may also experience burnout.    
        Smith (2004), reports during the past ten years meditation research has mainly focused on mindfulness meditation. Germer et al. (2005), suggests that the continued development of mindfulness-based research may lead to an integrated model of psychotherapy and mindfulness that supports the personal lives and professional careers of psychotherapists. Therapists may utilize mindfulness mediation in order to improve upon the personal experience of engaging with patients (Germer et al. 2005). Currently there appears to be a rebirth in interest about mindfulness and acceptance-based treatment approaches as evidenced by several recent research publications (Hayes, Follette & Linehan, 2004; Hayes, Masuta, Bissett, Luoma & Guerrero, 2004).                
        Recent research studies (Nanda, 2005; Shapiro et al. 2005; & Christopher et al. 2006), suggest that meditation may reduce the effect of burnout in the psychotherapist. Nanda in a phenomenological inquiry on the effect of meditation on the practice of psychotherapy reports that meditation helps the therapist be present and accept moment-to-moment experience. Christopher et al.’s research examined the effect of MBSR training during the education of healthcare professionals, and found that MBSR training early in the education of the healthcare professionals may help prevent burnout, lead to a reduction of stress, and lead to greater health for the healthcare professional in his or her career. Shapiro et al.’s research indicates that burnout was decreased (10% to 4%) and psychological stress decreased (23% to 11%) with MBSR.             
        Western attempts at developing mindfulness habits may be found in Freud (1961), free-floating attention, Rogers (1958), unconditional positive regard, and Feinstein (1994), studies on cognitive biases. Through the promotion of these qualities psychotherapists may improve clinical outcomes, be more aware of personal presence and experience a satisfying personal exchange with patients (Epstein, 2001). Mindfulness may have the potential to deepen the ability to experience a more satisfying professional practice (Epstein, 2001; Zoppi & Epstein, 2002). Epstein (2003, II) suggests that the quiet and stillness that accompany the practice of mindfulness may be essential for reflecting upon the practice of psychotherapy.
        Epstein (1998), describes the initial stages of meditation and analysis as an attempt to clarify the hidden mental processes and adapt to the internal flow of personal experience. Thus as the therapist is able to remain aware of the inner and outer experience or thoughts and emotions the two may mingle and establish a flow of health (Chadron, 1994). This flow of health may support the therapist in maintaining vitality, reducing stress and preventing burnout.         
        Meditation appears to promote well-being and may prevent burnout by lowering stress in psychotherapists. Therapists who practice meditation have noted fewer symptoms of burnout. Therapists, however may not find the time to learn, practice, or integrate meditation into the personal or professional daily calendar. The application of therapeutic fulcrums may suggest a simple in-session technique that does not require additional time for the therapist to gain the benefits, and to experience less stress and fewer burnout symptoms.
        This action research proposes to study the application of therapeutic fulcrums as an in-session technique that may prevent burnout in practicing psychotherapists. Therapeutic fulcrums may help psychotherapists to be more present to moment-to-moment therapeutic interactions and patient experience. According to Gilchrist (2000), therapeutic fulcrums may assist the therapist and patient in becoming more aware of personal thoughts, feelings, and physical sensations. Sills (2001), suggests that therapeutic fulcrums may help therapists organize his or her interactions with patients. According to Gilchrist (2000), and Sills (2001), therapeutic fulcrums may promote more effective, settled and clear therapeutic interactions. Therapeutic fulcrums may help the therapist be more at ease with patient interaction and experience less probability of burnout.
        Sutherland (1990, 2002) was the first to research the concept of therapeutic fulcrums in the field of healthcare. Sutherland researched physiology and function of the human body and how health could be restored. Sutherland spent thirty years researching the subtle movements of the cranium and how these movements relate to the health of the whole body.
        At the occipital bone there is a bony protrusion called the external occipital protuberance (EOP). Just anterior to the EOP is a junction of two membranes, the falx cerebri and tentorium cerebelli. The junction of the falx cerebri and tentorium cerebelli is called Sutherland’s fulcrum (Magoun, 1951, p. 39). The fulcrum at the joining of the falx cerebri and tentorium cerebelli membranes provides a still point for the tissues to balance. Similar to a balance scale and its central point of balance, the fulcrum is the point over which balance occurs. Sutherland suggests that if the balance point at this fulcrum is located through the felt sense of the cranial therapist, the cranial system will settle into a state of balanced tension.
        The cranial therapist utilizes inner awareness and sensitive hands to locate the still point of Sutherland’s fulcrum and affect the function of the body. When the cranial therapist is able to sense the location of the still point of the fulcrum, the shifting falx cerebri and tentorium cerebelli membranes begin to find balance and express a sense of ease. When the cranial therapist locates the felt sense of tension at the still point of the fulcrum and slightly retreats his or her hand pressure and presence, the cranial system may begin to find balance and restore health in the body. The cranial therapist utilizes therapeutic fulcrums to help in obtaining the subtle nuances and awareness needed to become aware of the still point at Sutherlands fulcrum and restore health to the patient (Gilchrist, 2000; Sills, 2001).
        Sills (2001), suggests that awareness of fulcrums may give the therapist clinical information and help deepen therapeutic presence, a fundamental quality that promotes health and healing (Gilchrist, 2000). The therapeutic fulcrums consist of three distinct anatomical locations: (1) external occipital protuberance, (2) mid-torso region of thoracic-10, (3) the coccyx (Gilchrist, 2000), and their associated vector points to the earth or ground. When the therapist accesses the therapeutic fulcrums a process of creating “sacred space” capable of establishing or promoting health and decreasing stress in the therapist or patient may occur (Sills, 2001).
        A term that may be helpful for the psychotherapist in understanding the concept of the fulcrum and still point is the term “equanimity” (M. Sills, 2000, p. 7). It simply means having enough space for the patient experience to unfold. Maura Sills suggests that the capacity of the psychotherapist to be open and receive, listen and feel what is in the present moment-to-moment experience, includes being open to personal thoughts and feelings at the subtle level.
        It is the psychotherapist’s challenge to find the stillness at the fulcrum by sensing and hearing (Sills, 2001). The ability to sense and listen for the stillness promotes the therapist’s ability to be open too patient process (Sills). As the psychotherapist is able to be still, the present moment-to-moment experience is filled with vitality and health for the patient (Jealous). Sills refers to this as a “sacred space” (p. 82). Sills, suggests for the therapist to settle into the stillness of the fulcrum, which may create sufficient space for the therapist to experience health thereby supporting the patient in his or her healing process. Sills (2001), and Gilchrist (2006), suggest that fulcrums provide a stable center that may benefit therapeutic relationship by providing a stable presence and awareness that can support patient development and health.
        As the psychotherapist is able to sense the still point of the fulcrum, the psychotherapist may sense a feeling of grounded presence or physical stability within his or her body. When the therapist settles into this still point of the fulcrum a clear relationship with the inner thoughts, feelings and health may be experienced by the therapist. According to Sills, the patient’s experience may also start to settle in a fulcrum. The fulcrum which the psychotherapist becomes aware of may also assist the patient in his or her therapy. Sills, suggests that this fulcrum grounds the therapeutic process and establishes a sense of stillness and “safe listening space” (2001, p. 82). Fulcrums support the psychotherapist in maintaining a secure sense of the therapeutic process as it occurs in moment-to-moment experience. This process of utilizing fulcrums was created in order to help the psychotherapist negotiate the subtle personal thoughts and feelings of the therapeutic relationship and simultaneously remain aware and open to the patient process (Sills).
Expected Results
        Expected results from the qualitative focus group may provide insight into how the study was received and offer information that may improve the outcome in future studies. Participants may experience very little benefit from the initial experience of working with therapeutic fulcrums, and may even gain greater benefit by being the observer in the practice group. This may be because as observers they are not compelled to feel a result. Participants may report a need for follow-up in order to process the impact of utilizing therapeutic fulcrums in their personal or professional interactions with patients.
        Expected results from the quantitative measures may be less than significant. It is generally assumed that a reduction of stress in the psychotherapist may take a minimum of three months to occur. Since this current study is only one day in length results may be less than significant, but will give possible ideas for future research.
        There are five recommendations that appear to need further exploration. One, Core Process Psychotherapy a Buddhist-based therapy developed by Franklyn and Maura Sills includes the application of therapeutic fulcrums, however the course is only offered in the United Kingdom (UK). Perhaps a student from the United States could complete the 6 year education in the UK, and publish the findings on the benefits of the fulcrums in psychotherapy.
        Two, there appears to be a rekindled interest in the scientific literature on the effect of burnout in the psychotherapist. There may be an opportunity to complete a dissertation such as this action research study presented here and publish the findings. There may be a need to present future workshops designed to guide the psychotherapist in his or her application of therapeutic fulcrums.
        Three, it may be possible to offer this technique to other professional healthcare providers. Specifically, registered nurses, ophthalmic technologists, dental hygienists, surgery assistants, and surgeons, may also experience burnout and could utilize the benefits of therapeutic fulcrums. Perhaps a future course at a technical school, college of fine arts or graduate level on health in the human service industry would be beneficial to the healthcare field.
        Four, the presented workshop is one day in length in order to encourage participation in the research. Future studies could address each specific fulcrum for its possible effectiveness or synergistic ability. Studies could also introduce additional locations on the body to address future therapist needs.
        Finally, it would be most interesting to find out what feedback other psychotherapists’ have regarding the possible benefits of therapeutic fulcrums once utilized for three months. Also, future research could compare the effectiveness of long term meditation practitioners that utilize therapeutic fulcrums compared to new students in the field of psychotherapy. Previous research appears to suggest that reducing stress may only be accomplished with long term treatment. Perhaps the in-session meditative technique suggested in this study is effective in preventing stress and burnout in less than three months, however a twenty year study may be required to confirm that burnout in the psychotherapist can be prevented with therapeutic fulcrums.

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Appendix A1
Interview Prior To Participation In    
Preventing Burnout with Therapeutic Fulcrums

Name _______________________ Name preference __________ Sex ___ Age ____

Address _____________________________ Email address _____________________

Marital status __________ Children (ages and sex):____________________________

Other dependents ______________ Level of education _________________________

Job title ________________ Facility ____________ Department _________________

Currently full time, part time, or contract ______ Number of years in profession _____

How did you hear about the study?

Health-Related Questions

How would you describe your present health?
Are you currently under the care of a physician or other health professional?
Please describe what medical problems, physical or emotional, you are receiving treatment for?
Are you on any medications? What are they and are there any side effects?

Have you had any major illnesses (e.g. heart attack, cancer) or surgeries?

Please describe.

Stress-Related Questions

What is stressful for you in your life right now at home and at work?

Do you worry? What are your greatest worries or fears?

What are the little things that irritate you?

Appendix A2

How do you know when you are upset?


How do others know when you are upset?

What methods (physical, emotional, mental, or spiritual), are practiced in order to cope with stress?  


 And how well do you feel you are coping?


Do you now, or have you ever, meditated? For how long (include daily average and for how many years)? Describe.


Do you have a support system? Who can you talk to when you’re upset?


What do you care about most? What’s most important for you?


What gives you the most pleasure and joy in your life?


What are your three goals for this program?




Appendix C1
Proposal for Preventing Burnout in the Psychotherapist with an
In-Session Technique, Therapeutic Fulcrums
Ludlowe Wellness Center

To:    Suellen Trumbore-Cheney
From:    Richard W. Crandall


The mind/body connection appears to have been effectively demonstrated in the fields of science and medicine. Stress management, and the possible prevention of burnout, may be an important part of health and wellness for the therapeutic community.

Stress management through the application of an in session meditative technique for therapists may lead to more effective treatments for patients and a prevention of burnout in the therapist. The Wellness Center has expressed an interest in hosting a class and research study in preventing burnout in the therapist.

It may be that for stress reduction to be successful however, change has to occur at the very core of the human being. Moment-to-moment awareness may also be necessary for change to occur at the core of our being. The application of an in session meditative technique, therapeutic
fulcrums may help the therapist develop moment to moment awareness necessary to change at the core of the human being.

Therapist tend not to take time out of the daily calendar in order to address this important health issue. The application of therapeutic fulcrums may be applied during the therapeutic session with minimal effect noticed by the patient. The therapist may experience greater awareness of personal presence, stability, vitality and perhaps less stress and a prevention of burnout.

The presenter of this one day class at the Wellness Center has been reshaping the practitioner fulcrum technique of Franklyn Sills and Roger Gilchrist. Although the content remains much the same, the context in which the material is presented differs. The context presented here is in session during a psychotherapy session whereas with Sills and Gilchrist therapeutic fulcrums are therapist-based and the patient may not be speaking.  Also, emphasis is placed on the practice of mindfulness which is cultivated through the formal practice of breathing awareness exercises, the body scan, and inner smile visualization. In order to acquire this ability to be more vital in session and with others at home or away from work each participant will need to practice in his or her
daily activities. As each participant becomes more aware of personal physical sensations., thoughts, and feelings, every moment may present as an opportunity to practice. Perhaps
 responding to stress may begin to replace stress reactivity and lead to a prevention of burnout.

Class Structure

This action research project is a requirement towards the degree of Master of Arts in Clinical Mental Health Counseling at Vermont College, Union University, and Institute. The research study will attempt to test the effectiveness of an in session meditative technique utilizing therapeutic fulcrums. The research study will be presented
Appendix C2

in an eight hour work shop during the course of one day.

Participants will be required to complete a health survey prior to attending the day-long work shop in order to determine eligibility for the study. Additionally, participants will be required to complete pre and post tests. These expectations are made known to each participant during an initial interview in the hope that motivated participants sign-up for the program. The minimum number of participants to conduct this study is set at six. The maximum number is set at twenty-four. There will be no fee required from participants. Class preparation will occur on the presenters time, as will all the time required for the initial interview, and focus group analysis.


Marketing of this program has been formal and informal. Names of those interested in the workshop have been received by email. Interested individuals have been notified through his or her professional counseling association. Additionally names have been collected from the presentations given at the Ludlowe, Vermont Wellness Center. Also announcements for the workshop have been posted at Dartmouth Hitchcock Medical Center, in Lebanon, New Hampshire.


Supervision for this research project will be provided by advisors at Vermont College. Advisors have supported future efforts for offering this workshop at other Wellness Centers and National Association Conventions. The Vermont College advisors have met with this presenter several times and have provided helpful feedback and suggestions for this study.


Richard W. Crandall










Appendix D

Association Web Site Addresses
Connecticut Mental Health Counselors Association

Maine Clinical Counseling Association

Massachusetts Mental Health Counselors Association

New Hampshire
New Hampshire Mental Health Counseling Association    

New York
New York Mental Health Counselor Association

Associated Psychotherapists of Vermont

Vermont Alcohol and Drug Abuse Counseling Certification Board

Vermont Mental Health Counseling Association

Additional State Associations
Any State







Appendix E

Are You Interested in Reducing Your
Stress and Burnout Symptoms?
The Ludlow, Vermont Wellness Center will be Presenting

Preventing Burnout in Psychotherapists
With an In-Session Technique utilizing
Therapeutic Fulcrums

at the beginning of next year.
If you would like further information,
please contact Richard Crandall
leave your name, occupation, and work phone number or email address
and you will be contacted.

Thank you!

Appendix F

An introductory talk: An in-Session Technique
For Preventing Burnout in Therapists

When:   Tuesday, January 29, 2008
From:    6:30 to 8:00 pm
Where:  Ludlowe Wellness Center

OR      Friday, February 16th, 2008
12:00 to 1:00 pm in the Ludlowe Wellness Center

Who:    Anyone interested!

For more information, contact Richard Crandall at 802 282-1068 or Email


Appendix G

As a licensed professional psychotherapist or counselor you have volunteered to be a participant in a study to determine the effects, if any, of an in session meditative technique, therapeutic fulcrums offered through the Ludlowe, Vermont Wellness Center, on your health and well-being. The study is being done by the investigator for a Master’s thesis in Clinical Mental Health Counseling from the Department of Psychology at Vermont College, Union Institute and University.

As a study participant you will be asked to attend an eight hour class for one day. This program is modeled on the work of Franklyn Sills, Roger Gilchrist and Mantak Chia. The class sessions include lecture, group discussion, and the practice of mindfulness through breath awareness, the body scan, meditation, and inner smile. Before the first class you will be asked to complete an informal health assessment interview, and after the last class you will be asked to complete pre and post tests measuring health and well-being. The risks of this study are minimal. Because mindfulness, or moment-to-moment awareness, is the main focus of this program, you are supported in paying attention to, and honoring, your own limits and needs at all times.

The benefits of the study may be a decrease in any physical symptoms that are stress-related, an increase in energy, an increase in the ability to relax and sleep, a decrease in anxiety and burnout symptoms, an ability to cope more effectively with stressors, and an increase in social connectedness and feelings of well-being. There is no guarantee, however, that you will benefit from this study.

Any data published will not reveal the identity of the subjects. You are free to withdraw your consent and discontinue participation in the program at any time. There will be no cost to you except lunch and transportation.

Should any complications arise, the investigator will be available for consultation and will assist you in obtaining the appropriate referral or treatment but this study does not provide financial assistance.

Your signature indicates that you have read and understand the above information, that you have discussed the study with the investigator, that your participation is based on the information provided, and that a copy of this form has been given to you.

Participant’s Signature ……………………………………… Date……………

Investigator/Witness Signature                               Date……………





Appendix K
Lateral view of spine

Upledger, 1997, p. 13
Appendix M
The divisions of the dura mater within
the cranium: falx and tentorium

Gilchrist, 2006, p. 32



Appendix L
Fulcrum as posterior extension of straight sinus
Sills, 2001, p. 87


Appendix P1

Name __________________________ Address __________________

Home Phone ____________________ Work Phone _______________

Occupation _____________________ Referred by________________

Date of Birth_____________________ Email____________________

In an emergency who should be notified?
Their number _____________________

Do you have a physician, osteopath, chiropractor or naturopath?

When was your last visit with them?

Are you taking medication?           Please specify:

Have you recently been on a course of antibiotics? When, and for how long?
Do you have any allergies?           Please specify:

Do any of your family members have allergies?

What is the health status of your parents?

Do you smoke?   Do you exercise?          Favorite exercises?

Describe your main health complaint?

What do you want to work on today?
What is your accident history (auto, sports, ice, or staircase)?

Appendix P2

What bones have broken?

Have you strained or sprained anything?

Do you have a history of head injury or emotional trauma?

Please list Surgery History?

Do you have any long-term treatment goals?    

Do you suffer from daily stress?

How often do you suffer from headaches or migraines?

Are you expecting?

Is anyone in your family diabetic?

Do you have cardiac or circulation problems?

What is your blood pressure usually?

Ever have a seizure, stroke, or epilepsy?

Do you have a history of asthma, ulcer, colitis, varicose veins, cancer, chemotherapy,

or diabetes?    

What are your allergies?

Do you experience cramps?    If so when?

Are you in pain now?

Is there any numbness or stabbing pains?

Do you practice meditation or yoga?

How many hours do you sleep?

Do you take recreational drugs?

Do you drink for stress reduction regularly?

Appendix P3

Do you smoke cigarettes?

Do you abuse medications?

What is the health of your parents?

Do you have a talk therapist, spiritual mentor or support group?

When was your last visit with them?

Is there anything else you should bring to my attention?

Please rate each of the following symptoms according to the way you have felt during the

last month. Use a scale of zero to four, as follows: 0=never/almost never,

1=occasionally/not severely, 2=occasionally/severely, 3=often/not severely,



_____Nausea/vomiting _____Diarrhea _____Constipation

_____Bloating-Gas/Belching _____Heartburn



_____Moody _____Anxious, Fearful, Nervous, Stressed

_____Angry, Irritable, Aggressive    _____Depressed


Joint & Muscular

______Joint Pain or Aches _____Arthritis (dry or inflamed)

______Stiffness/Limited Movement

Appendix P3

_____Muscle Pain or Aches

_____Feeling of Weakness or Fatigue



_____Acne _____Hives/Rashes/Dry Skin _____Hair Loss

_____Flushing/Hot Flashes Excess Sweating


Vitality, Energy

_____Tiredness, Fatigue _____Apathetic, Lethargic

______Hyperactive ____Restless    


I affirm that I have stated all my known medical conditions. I agree to keep my

therapist up-to-date on any changes in my medical profile. I understand that there

shall be no liability on the psychotherapist’ part should I forget to do so. I further

understand confidentiality has limits and that my therapist is a mandated reporter and by

law must report to the appropriate state authority any unreported child abuse.

Patient_______________________________ Date______

Psychotherapist________________________ Date______

Observer _____________________________ Date______



Appendix R

is presenting a one day workshop and research study on


Friday from 8:30 to 5:30 p.m.
March 21, 2008

Is life going by too quickly? Do you feel the need to
slow down and be still? Do you respond with habitual
ways of reacting? Do you feel you are missing
something as life passes you by?

Learn how to access your own inner resources to cope
with stress, to experience life in its fullest, to become fully alive.

These classes are based on mindfulness, or moment-to-moment
awareness, which is cultivated through the formal practice of
breath awareness, meditation, and yoga. This paying attention to
one’s experience in the moment is also practiced informally in our
daily lives, at home and at work, to help reduce stress.

Modeled on traditional health maintenance programs of
Dr. Sutherland D.O., Dr. Randolph Stone D.C., D.O.,
Dr James Jealous D.O., Franklyn Sills RCST, and Roger
Gilchrist MA, this program is research project for a Master’s
Thesis in Clinical Mental Health Counseling.

Further information concerning this will be provided to participants.
There is no cost for this eight hour one day class.

For information call Richard Crandall at 802 282-1068
or email

Appendix S
March 31, 2007    
Review Board for
Human Subject Approval

To Whom It May Concern:

I am a student at Vermont College Union Institute and University fulfilling requirements for a Master of Arts degree in Clinical Mental Health Counseling for twenty years now I have been interested in the mind/body connection and have been practicing counseling, craniosacral therapy and teaching meditation, yoga, and nutrition to patients at various agencies in Vermont and New Hampshire. This has been an attempt to provide stress management classes and health restoration for patients in the Upper Valley region of the Connecticut River Valley. It is with this latter work that I am planning to do some research for my Master’s thesis at Vermont College.

I plan to offer a one day workshop on the prevention of burnout in psychotherapists with an in session meditative technique utilizing therapeutic fulcrums. I plan to offer this work shop to interested therapist in the New England states. The work shop will be
presented at the Ludlowe Wellness Center.

This class will attempt to cultivate mindfulness through the formal daily practice of breath-work, the body scan, meditation, and inner smile. This program will be modeled after the work of Franklyn Sills, Roger Gilchrist and Mantak Chia. Although this project is similar to that presented by Sills and Gilchrist, the therapists in this setting will be psychotherapist and not craniosacral therapists.

Assessments (quality of life, burnout inventory and vitality), will be given to each participant during interviews I will conduct both before and after the series of classes. Research will be both quantitative through these measurements and qualitative through a focus group.All participants will sign an Informed Consent.

I have met several times with my advisors at Vermont College. They have both expressed an interest in this research, and have provided valuable feedback and suggestions.

I am writing to you to determine if I need human subject approval, and if so, if that could be obtained. Is there any other approval need before I conduct the research I described with psychotherapists from the New England states. If you have any questions, please feel free to call 802 282-1068 or email me at

Richard W. Crandall





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