Mindfulness Meditation As Psychotherapy

By Migel Jayasinghe

Until quite recently the treatment of choice for depression, and for many other conditions identified as psychiatric illnesses, has been Cognitive Behaviour Therapy (CBT). Historically, CBT developed from a coming together of two strands of therapy known first separately as Behaviour Therapy, and a later development known as Cognitive Therapy. While CBT is the approved mainstream 'talking cure' periodically subjected to experimental validation by the scientific community, there are also drug-induced treatments which are subject to periodic testing for efficacy. It is informative to note that Behaviour Therapy developed at a time when psychology regarded classical and operant conditioning as sufficient mechanisms in explaining human behaviour. Later when psychology took on board the mediation of thought and language (what went on inside the 'black box') as equally, if not more important in explaining human behaviour, Cognitive Therapy was born.

CBT is approved by the National Institute for Clinical Excellence (NICE) in the UK. However, since no one therapy (including medication) has been proved to be universally beneficial for all patients, the field of counselling and therapy is replete with many alternatives such as psychoanalysis, Gestalt Therapy, NLP and other 'talking' therapies. These are not seen as 'scientific', objective, and amenable to quantitative research. Increasingly, with the passage of time, it appears that 'mind' a concept that had been totally alien to 'scientific', positivistic psychology, was beginning to be accepted, at least in the form of neural activity in the brain underpinning all mental schemata as the basis of behaviour.

From here, it has been quite a jump to accept 'mindfulness meditation', borrowed from the Hindu and Buddhist traditions practised as a religious observance for more than 2500 years as a means of reaching enlightenment. So, Mindfulness-based Cognitive Therapy (MBCT), may be seen as an innovation in therapy through an attempt at a fusion between two widely divergent fields of human endeavour separated not only by time of origin but by distinctiveness of culture as well . Even so, it is reported that over the last two decades MBCT appears to have proved efficacious in treating persistent or recurring depression in psychiatric patients.

Meditation in mindfulness is the cultivation of awareness of the activity of one's consciousness from moment to moment. When one is able to accomplish this, it can stop one being trapped in constant ruminations and automatisms in thinking and mood. This is best achieved by concentrating on one's breathing (in and out) without attempting to control the flow of thoughts. Alternatively one can scan one's bodily sensations from head to toe. For those who are able to distance themselves from their daily stream of thoughts and sensations, the reward is perfect bliss. 'Sadhus' in India have been known to remain seated in the lotus position for months, if not years.

Where the use of mindfulness meditation differs in its use in therapy, is that the object of the exercise is to monitor and stop the stream of negative thoughts by enabling the patient to realise that such thoughts and the resulting negative mood or depression are not inevitable. There is no religious or transcendental objective beyond the capacity for healthy everyday living by the patient who is expected to reduce the odds of being caught again in a spiral of depressive rumination through mindfulness meditation.

Originally developed by Prof. Jon Kabat-Zinn of the University of Massachusetts Medical Center in 1979, it was then an 8-week programme designed for stress reduction. Research shows that MBSR (Mindfulness-Based Stress Reduction) is enormously empowering for patients with chronic pain, hypertension, heart disease, cancer, and gastrointestinal disorders, as well as for psychological problems such as anxiety and panic. Several studies have been undertaken which led to the conclusion that MBCT was most effective in the treatment of patients who had suffered three or more episodes of depression in the past.

What are the mediating variables or mechanisms that are at work in mindfulness meditation which ameliorate these 'different pathologies'? One of the hypothesised mechanisms is the concept of 'defusion' where patients learn to distance themselves from the stream of recurring negative thoughts without attempting to change the thoughts themselves. Mindfulness allows the patient to observe or witness the mental activity moment by moment, thereby creating a space between the culturally constructed inner commentary, and grasp the insight that another, completely different self, or selves, is a possibility. A stable self that one identified oneself with in the past is no longer seen as inevitable.

Teasdale, J.D., Moore. R.G., Hayhurst, H., Pope, M. Williams, S. & Segal, Z.V. (2002) developed the Differential Activation Hypothesis (DAH) to account for mediating mechanisms in MBCT treatment. In studying patients with a history of relapses into depression, they found that often transient negative moods led to negative thought patterns which spiralled into full-blown depressive episodes. Taught to practise mindfulness meditation, these patients learned to become aware and identify early, their transient negative moods which, for them, automatically led to negative thoughts culminating in a relapse. Mindfulness to these patients meant an act of 'decentering' that helped to prevent the automatism connected with the downward spiral towards a relapse. Patients learned to become aware of their thought processes and to disengage from ruminating through acceptance of them as mere thoughts and not needing to identify themselves totally with the thought patterns.

In a more recent article by Shapiro, S.L, Carlson, L.E., Astin, J.A. & Freedman, B. (2006) entitled 'Mechanisms of Mindfulness' a new theory is proposed which addresses what are seen as limitations of the 'defusion' and 'decentering' hypotheses discussed above. While acknowledging the validity and usefulness of the earlier described mechanisms, Shapiro et al say that a 'testable theory of the mechanisms involved in the process of mindfulness itself is needed to explicate whether and how mindfulness affects change and transformation' (op cit.). They credit some of the early researchers into mindfulness with having developed 'valid and reliable measures of mindfulness' (Baer, 2003, Bishop, 2002, Brown & Ryan 2003).

A definition of mindfulness is - 'paying attention in a particular way: on purpose, in the present moment, and non-judgmentally' (Kabat-Zinn 1994). Using this definition Shapiro et al have identified three axioms of mindfulness.

1. "On purpose" or intention,

2. "Paying attention" or attention,

3. "In a particular way" or attitude (mindfulness qualities).

'Intention, attention and attitude (IAA) are not separate processes or stages - they are interwoven aspects of a single cyclic process and occur simultaneously. Mindfulness is this moment-to-moment process (Shapiro et al 2006).

Intention, according to Shapiro et al is at the heart of mindfulness meditation. This aspect of meditation is often lost in adapting it to therapeutic purposes. Enlightenment or self-liberation was the original goal or intention of religious practitioners of mindfulness meditation. In therapy, self-exploration and self-regulation must be seen as goals that are dynamic and evolving and equally valid for both the patient and the therapist. Without a clear early identification of intention, mindfulness meditation is in danger of drifting into aimlessness.

Attention is the second component of mindfulness meditation. 'In the context of mindfulness practice, paying attention involves observing the operations of one's moment-to-moment, internal and external experience ... At the core of mindfulness, is this practice of paying attention' (op. cit.). Attention is common to most therapeutic practices. For example in Fritz Perls' Gestalt therapy, awareness of the present moment and attention to it is said to be 'curative' in itself. CBT also stresses the importance of attending to (observing) internal and external stimuli.

Attitude is explained as the qualities one brings to mindfulness meditation. It is not a cold and abstract intellectual exercise, but a warm and engaged openhearted activity. The attitude is one of affectionate, compassionate involvement. '... attending without bringing the heart qualities into the practice may result in (a) practice that is condemning or judgmental of inner experience. Such an approach may well have consequences contrary to the intentions of the practice. For example, cultivating the patterns of judgment and striving instead of equanimity and acceptance' (op. cit.).

Having set down the three essential axioms or building blocks for the theory they propose, Shapiro et al go on to postulate 'a model of the potential mechanisms of mindfulness, which suggest that intentionally (I) attending (A) with openness and non-judgmentalness (A) leads to a significant shift in perspective which we have termed reperceiving' (op. cit.). This involves a disidentification from the contents of consciousness (thoughts) and cultivating an ability to stand back and witness the never ending drama of our unfolding individual life story. Concepts already employed by western psychology which are similar to reperceiving are: 'decentering', deautomatization and 'detachment'. All these concepts share at their core a fundamental shift in perspective. This shift ... is facilitated through mindfulness-the process of intentionally attending moment by moment with openness and nonjudgmentalness (IAA) (op.cit.)

Shapiro et al further discuss statistical models that could be employed to test their theory. They are careful to underline the fact that research into mindfulness is 'still in its infancy and requires great sensitivity and a range of theoretical and methodological' approaches 'to illuminate the richness and complexity of this phenomenon' (op. cit.).

The strengths in the exploration of postulated mechanisms in mindfulness meditation are that they are conducted by practitioners who appear to build on the scholarly and scientific investigations of others in the forefront of MBCT therapeutic practice. They seek to aim at a consensus. The weaknesses stem from the fact that positivistic scientific hypothesis testing requires the isolation of a few variables and crude statistical analyses to examine very complex phenomena not necessarily amenable to scientific exploration. Every encounter between therapist and client is a unique one where by the very nature of the context, an objective generalizable theory can only be an approximation unlikely to be falsifiable applying scientific criteria.

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