MINDFULNESS MEDITATION: AN INTEGRATION OF PERSPECTIVES FROM BUDDHISM, SCIENCE AND CLINICAL PSYCHOLOGY

A Dissertation Submitted to the Faculty of the California Institute of Integral Studies

by Miles I. Neale

In Partial Fulfillment Of the Requirements for the Degree of Doctor of Psychology

San Francisco, California 2006

CERTIFICATE OF APPROVAL

I certify that I have read Mindfulness Meditation: An Integration of Perspectives from Buddhism, Science and Clinical Psychology by Miles I. Neale, and that in my opinion this work meets the criteria for approving a dissertation submitted in partial fulfillment of the requirements for the Doctor of Clinical Psychology degree in Clinical Psychology at the California Institute of Integral Studies.

______________________________________ Denise Scatena, Ph.D. Professor of Psychology Committee Chair

______________________________________ David Lukoff, Ph.D. External Reviewer

 2006 Miles I. Neale

Miles Ian Neale Denise Scatena, Ph.D., Committee Chair California Institute of Integral Studies, 2006 MINDFULNESS MEDITATION: AN INTEGRATION OF PERSPECTIVES FROM BUDDHISM, SCIENCE AND CLINICAL PSYCHOLOGY ABSTRACT Mindfulness meditation is a two-and-a-half millennia-old Buddhist spiritual practice that focuses on the development of introspective consciousness. The present research provides a comprehensive, multiperspective overview and synthesis of the applications and effects of mindfulness meditation. The need for the current study is significant given that recently in the West mindfulness meditation has increasingly been a subject for empirical investigation, as well as a clinical intervention for a wide variety of medical illnesses and psychiatric disorders. The objective of the current study was thus to integrate the traditional Buddhist aspects of mindfulness with findings from contemporary empirical research. In conducting this integration, the theory, application, and effects of mindfulness meditation as described in early Buddhist psychology was reviewed. A comprehensive literature review of the past 50 years of health-related studies was then undertaken to determine the physiological, neurological, and psychological effects of mindfulness

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meditation, as well as its efficacy as a treatment protocol in a clinical context. The specific areas of focus for the literature review included meditation, concentration, mindfulness meditation, mindfulness-based stress reduction (MBSR), mindfulness-based cognitive therapy (MBCT), dialectical behavior therapy (DBT), attentional control, insight meditation, Buddhist meditation, vipassana, and mind/body medicine. Publications of theoretical nature, single case studies, clinical trials, meta-analyses, existing reviews of the literature and scholarly books in the areas of focus were included. In this review significant neuro-biological and clinical evidence to suggest that mindfulness meditation is an effective treatment for a wide range of medical and mental health issues was found and discussed, including points of convergence and mutual relevance between these current Western applications and traditional Buddhist perspectives. It was concluded that there is a need for a greater number of fullscale clinical trials regarding the effects of mindfulness meditation in the clinical context, with an emphasis on more rigorous methodological standards. In addition, it was concluded that Buddhist theory and applications of mindfulness meditation have yet to be sufficiently analyzed and synthesized into Western applications in health-related contexts.

DEDICATION This work is dedicated to my mentor, Dr. Joseph J. Loizzo An ideal introject who rouses my optimal potential. Whose belief in me internalized as a seed of self-confidence. Who guided me into the lineage of the jewel tree refuge. All credit belongs to you, all blame I drive into one! May the adversity I endured during graduate training, Purify my past negativity. And may the merit accrued, Be dedicated to the liberation of all sentient beings. Welcome blade-wheel you have again come full circle!

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AKNOWLEDGMENTS

This project was influenced and inspired by several people, whom I would like to acknowledge. I would first like to thank my committee chairperson, Dr. Densie Scatena for her patience and guidance through this challenging dissertation process, and for respecting and fostering my unconventional learning style and interests. Thanks also to my external review member, Dr. David Lukoff, for his thoughtful critique and suggestions that assisted in improving my work, and for his professional contributions to the emergence of spiritual diagnoses and treatments in mainstream psychology. I would like to express my deep appreciation to several Buddhist teachers who blessed me with their wisdom and compassion, including my guru, the late Achariya Godwin Samararatne, with whom I took refuge under the Bodhi tree in Bodh Gaya at age 21. Godwins simplicity and delight in teaching loving-kindness and mindfulness provided a propitious entryway into the unbroken legacy of the Buddha and have remained a continuous inspiration throughout this project and my life. My gratitude extends also to my teachers at Tibet House, New York, including Dr. Robert Thurman for his sharp intellect, animated charisma and refined craft in conveying the magnificent jewel of Tibetan Buddhism and Dr. Mark Epstein for his elegant and lucid presentations of the interface between Buddhist meditation and psychotherapy.

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Finally, I am grateful to my parents, Ian and Michele Neale, and my brother Julian for their unconditional acceptance and financial support, as well as to my dear friends Nasli Batliwala, Michael Sheehy, Kemal Arsan, Brooke Radder, Dan Hirshberg and Emily Wolf, for their companionship along this sojourn. None of this would be possible or even worthwhile without them. In our interactions I have glimpsed the dawning of interconnectivity. Continue all to fearlessly fallow the blue light into the life between.

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TABLE OF CONTENTS

Abstractiv Dedicationvii Acknowledgments...viii Chapter 1: Introduction..1 Defining Mindfulness Meditation2 Significance of the Study...6 Purpose of the Study.7 Chapter 2: Approach and Method..9 Integrative Literature Review Method.9 Data Gathering Procedures...12 Key Words and Search Terms...13 Buddhist Texts14 Organization of the Study.........15 Chapter 3: Mindfulness Meditation in Early Buddhist Psychology19 Origins of the Buddha and His Teachings....19 History of the Buddha20 Teachings of the Buddha23 The Three Vehicles...23 The Four-Noble Truths Framework....24 First Noble Truth..25 Second Noble Truth..26

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Third Noble Truth.27 Forth Noble Truth...28 Freedom From Suffering29 Selflessness...29 Overcoming the defilements..31 The Three Higher Trainings .33 Ethical conduct (Sila)...33 Attentional control (Samadhi)....33 Wisdom (Prajna)..34 Buddhist Meditation Techniques and Topographies...34 Concentration Meditation .36 The Three Realms of Experience ...37 The first realm...38 The second realm..38 The third realm.39 The Path of Concentration..39 Mindfulness Meditation .41 Buddhist Instructions and Texts on Mindfulness42 The Path of Insight ..46 Insight Stages 1 and 2..47 Insight Stage 3..48 Insight Stage 4..49 Insight Stage 5..49

Insight Stages 6 and 7..50 Insight Stage 8..51 Summary.53 Chapter 4: Mindfulness Meditation in Mind/Body Medicine.55 Towards a Science of Enlightenment..55 History of Clinical Meditation Research 59 Physiological Effects of Mindfulness ..64 Cardiovascular System and Disease...66 Blood Pressure and Hypertension ..69 Metabolic and Respiratory System .71 Muscle Tension .71 The Value of Mindfulness Meditation in Medical Populations72 Chronic Pain .72 Anxiety ..75 Psoriasis .80 Cancer ...82 Summary...86 Chapter 5: Mindfulness Meditation in Cognitive Neuroscience.. .88 Introduction...88 Neurological Correlates of Mindfulness Meditation...91 EEG and Alpha Activity91 Alpha Blocking Versus Alpha Habituation..95 EEG and Theta Activity100

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Brain Laterality and Hemispheric Dominance101 PET, fMRI and EEG Studies..105 Neuroplasticity..112 Summary.115 Chapter 6: Mindfulness Meditation in Clinical Psychology.118 Introduction.118 Buddhism and Clinical Psychology..120 Mindfulness Meditation Compared to Psychotherapy123 Theoretical Models Combining Techniques126 The Sequential Model128 The Simultaneous Model...130 Mindfulness Meditation and Ego Development..132 The Ego Ideal and the Ideal Ego...135 Reparenting the Ego.137 Contraindications of Mindfulness Meditation...140 Complications and Negative Effects...140 Regression to Primary Narcissism...141 Emergence of Repressed Material142 Review of Adverse Effects144 Stage Model of Meditative Complications...144 Stage 1. Preliminary practice.145 Stage 2. Access concentration146 Stage 3. Samadhi146

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Stage 4. Insight...147 Clinical Value of Mindfulness Meditation148 Mindfulness Meditation: Adjunct to Psychotherapy...148 Mindfulness and Short-term Therapy...148 Mindfulness and Long-term Therapy..148 Mindfulness and Psychoanalysis..150 Mindfulness-Based Psychotherapies...152 Mindfulness-Based Cognitive Therapy....152 Dialectical Behavior Therapy156 Mechanisms of Clinical Effects in Mindfulness...160 Exposure161 Cognitive Change.162 Self-management...163 Relaxation...164 Acceptance.164 Deautomatization..166 Lifting Repression..167 Existential Relief.168 Meta-Analyses and Methodological Issues .171 Points of Comparison Between Meta-Analyses..171 Inclusion Criteria...171 Target Populations.172 Mean Effect Size.172

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Methodological Weaknesses..173 Potential Benefits.176 Summary.178 Chapter 7: Integration and Synthesis.179 The Central Role of Disidentification...179 Disidentification in Buddhist Meditation180 Disidentification in Mind/Body Medicine..184 Disidentification in Neuroscience186 Disidentification in Psychotherapy.186 Buddhism and Psychology Reconsidered..187 Chapter 8: Conclusion...191 Recommendations for Future Research.192 Methodological Rigor...192 Specific Areas to Be Addressed192 Qualitative Data and Subjective Accounts..194 Further Implications.195 Secular Versus Traditional Meditation.195 Qualifications of the Clinician...196 Reintegration: A Return to the Buddhist Origins198 Concluding Remarks203 References 206 Appendix A: Abbreviations of Buddhist Texts...240 Appendix B: Glossary of Buddhist Terms...241

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CHAPTER 1: INTRODUCTION

In the last several decades, within various disciplines of western healthcare, there has been a burgeoning interest in complementary and integrative treatments for mental and physical disorders. While great strides have been made in surgical and pharmacological protocols, and while biomedical research continues to reveal more precise and effective treatments for a wide range of diseases, mechanistic and reductionistic approaches have increasingly been recognized as limited. A holistic framework has recently emerged to address the shortcomings of the allopathic medical model, developed within the dualistic Cartesian paradigm of the early 17th century. Rather than target symptoms alone, integrative approaches seek to provide greater health benefits and lasting relief by focusing on the mind/body connection. These approaches address negative attitudes, behaviors, and lifestyles, which underlie disease and psychopathology. This growing interest in both popular and professional circles within the United States and Europe, that safe, effective, and inexpensive alternatives are needed to complement conventional healthcare, results from two separate factors: First, the cost of modern medicine is increasing due to the complexity and sophistication of current treatments; and second, there is an escalating number of so-called diseases of civilization, where conventional surgical, psychotherapeutic, and pharmacological treatments are only partially effective (Loizzo, 2000). These stress-exacerbated diseases include, anxiety, depression, and addiction, as well as heart disease and cancer. As a result, Western 1

researchers have looked to traditional systems of healing found in other parts of the world, such as meditation and yoga, for examples of noninvasive, self-care regimens that have stood the test of millennia of human use (Davidson & Harrington, 2001; Goleman, 1979, 1981, 2003a, 2003b; Gyatso, 1997; Gyatso, Benson, Thurman, Gardner, & Goleman, 1991; Hayward & Varela, 2001; Houshmand, Livingston, & B.A. Wallace, 1999; Zojonc, 2004).

Defining Mindfulness Meditation Traditionally, meditation has been a broad term used to categorize an array of spiritual forms of introspective consciousness-shaping practices. Recently, the term meditation has gained more frequent use in medical literature, indicating a shift from its primary designation as a religious practice to a more widespread definition as a secular means to help train ones attention (Kabat-Zinn, 1994). In their 1996 work, Mandle, Jacobs, Arcari and Domar pointed out that there were over 1,000 studies on meditation that could be found in the literature, with the number currently having grown to more than 1,500 (Gremer, Ronald, & Fulton, 2005). This increase reflects a growing interest in determining and verifying the health benefits of meditation. On the other hand, the misperception, pervasive in early research, that all meditation techniques were alike, negated the unique psychological effects, therapeutic value, and even the potential complications associated with different practices (Dunn, Hartigan, & Mikulas, 1999).

Since the late 1950s Western physicians, psychologists, and health researchers have been studying the psycho-physiological effects of various types of meditation, resulting in several literature reviews (Barrows & Jacobs, 2002; Banadonna, 2003; Jarrell, 1985; Murphy & Donovan, 1999; D. H. Shapiro & Walsh, 1983; West, 1987). The most widely known and researched techniques are Transcendental Meditation (TM) (OrmeJohnson & Farrow, 1977) and Bensons (1975) relaxation response method. The present research focuses exclusively on the Buddhist practice known as mindfulness meditation (Skt, smirti; Pali, sati) and its more advanced derivative, insight meditation (vipassana). Mindfulness comes from the Pali word sati and the Sanskrit word smirti, which connotes awareness, attention, and remembering. The background and foreground of consciousness are, respectively, awareness and attention. Awareness provides global scanning and continuous monitoring of experience, while attention heightens sensitivity towards a restricted amount of experience, allowing for a deepening of ones focus and investigation. The term remembering is also pivotal, given the fact that mindfulness is the continued intention to remain present, and to volitionally refrain from mental engagement that disrupts the unity of awareness and attention (Gremer, Ronald, & Fulton, 2005). Mindfulness has been variously defined as paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally (Kabat-Zinn, 1994, p. 4); as bringing ones complete attention to the present experience on a moment-to-moment basis (Marlatt & Kristeller, 1999, p. 68); and, simply as attentional control 3

(Teasdale, Segal, & Williams, 1995, p. 54). A more psychologically oriented description defines mindfulness as a limber state of mind (Langer, 1989, p. 70); and as a cognitive process that employs the creation of new categories, openness to new information, and awareness of more than one perspective. According to Hirst (2003), being mindful requires the person to attend, to be consciously aware of, the emergent nature of phenomena in consciousness, and to recognize the nature of attachments made to these phenomena as they occur (p. 360). Mindfulness is more than a cognitive, perceptual function; it is awareness of present experience with acceptance (Gremer et al., 2005, p. 7). Kabat-Zinn (1990) and Shapiro, Schwartz, and Bonner (1998) list 12 qualities or attitudes that support the practice of mindfulness, including nonjudging, nonstriving, acceptance, patience, trust, openness, letting go, gentleness, generosity, understanding, gratitude, and loving kindness. Vietnamese Buddhist meditation master Nat Hanh (1976) defines mindfulness as, keeping ones consciousness alive to the present reality (p. 11); while the German Buddhist monk and scholar Nyanaponika (1972) describes it as the clear and single minded awareness of what actually happens to us and in us at the successive moments of perception (p. 5). The Sri Lankan monk, Gunaratana (1991), provides a more esoteric explanation, stating that mindfulness cannot be fully captured in words, because it is subtle, nonverbal, beyond conception, and must ultimately be experienced. Mindfulness is both a psychological state of receptive awareness, and a systematic meditation practice that is used to develop skill in 4

nonjudgmental perceptual receptivity. The reader should note that for the remainder of the research the term mindfulness refers to the actual meditation practice. For those interested in the former, Langer (1989) discussed the cognitive model of mindfulness without emphasis on the meditative approach. Mindfulness can also be contrasted with mindlessness, a state of being as if on automatic pilot, involving preoccupation, forgetfulness, carelessness, inattention, disassociation from thoughts and feelings, and habitual response (Brown & Ryan, 2003). Langer (1989) adds that mindlessness is distinguished from mindfulness by behaviors that are guided by habit, trapped by rigid mind sets, and oblivious to time, context, or novel perspective. Although interest in mindfulness has increased within the past 10 years, various researchers (Bishop, 2002; Feldman, Hayes, Kumar & Greeson, 2004) have argued that the term itself has yet to be sufficiently operationalized, thereby compromising research and making it difficult to measure its construct validity. In response, Bishop et al. (2004) recently proposed the following operationalized definition of mindfulness: sustained attention of present experience with an attitude of openness, curiosity, and acceptance. Generally speaking, such variations in definition depend upon the domain of psychology in which the subject is discussed, either clinically or nonclinically. Clinical definitions are more consistent with the traditional concept of mindfulness in Buddhism, emphasizing present moment awareness with attitudes of acceptance and nonjudgment towards unpleasant and distressing experience. Nonclinical definitions emphasize concepts of learning and creativity. 5

Significance of this Study Although mindfulness meditation has its origin in the 2,500-year old pan-Asian Buddhist tradition, it is now relevant to the contemporary medical and psychiatric disciplines of the West. Along with other meditation practices researched in the last 50 years, mindfulness meditation has grown from a relatively unfamiliar concept, to a controversial and misunderstood technique, to a generally accepted therapeutic intervention with proven efficacy. A large number of empirical reviews focusing specifically on mindfulness meditation have recently appeared in the literature (Baer, 2003; Banadonna, 2003; Bishop, 2002; Brown & Ryan, 2003; Gremer et al., 2005; Grossman, Niemann, Schmidt, & Walach, 2004; Hirst, 2003; Loizzo, 2000); several standardized treatment protocols incorporating mindfulness are now available (Hayes, Strosahl, & Wilson, 1999; Kabat-Zinn, 1982; Linehan, 1993b; Loizzo, 2004; Marlatt & Gordon, 1985; Segal, Williams, & Teasdale, 2002); more than 240 hospital and clinics nationwide and abroad offer mindfulness-based health programs for patients (Salmon, Santorelli, & Kabat-Zinn, 1998); and National Institute of Health initiatives to fund such centers reflect a consensus among professionals about their cost-effectiveness and proven clinical value (Goleman & Gurin, 1993). As the visibility and utility of mindfulness meditation increase in Western culture, clinicians and researchers will be asked by their patients and colleagues to evaluate current empirical findings, provide clinically sound treatment recommendations, and knowledgeably discuss the nature, benefits, and limitations of these techniques. This may pose an 6

unexpected difficulty, given that only a short time ago meditative techniques were dismissed either as a placebo or as an obsessive religious ritual from foreign cultures (Loizzo, 2000). The present study offers an integrative review of classical Buddhist and contemporary empirical findings. These findings provide an overview of the potential effects and benefits of mindfulness meditation, while placing it in the therapeutically rich paradigm from which it originated, that of Buddhism. The growing empirical support and popular demand for integrative approaches to health and well-being make a review of the empirical evidence of mindfulness meditation necessary and timely. Such a study would be useful to both individuals in the public sector who wish to make informed choices about their healthcare options, and to practicing professionals who want to develop complimentary approaches to treatment.

Purpose of the Study The purpose of this study was to integrate Buddhist, scientific and clinical perspectives regarding the effects of mindfulness meditation, in order to provide a more comprehensive presentation of the subject, including empirical and clinical areas of Western investigation, contextualized within the seminal Buddhist tradition from which it arose. First, I examined the utility and effects of mindfulness meditation from the Buddhist perspective to provide the contextualizing foundation often neglected in secularized investigations and applications created by researchers and clinicians for the western population. Second, I reviewed the neuro-psycho-biologic effects of mindfulness meditation as presented 7

in the last 50 years in scientific research. Third, I examined the manner and degree of success in which mindfulness meditation has been utilized therapeutically as a clinical intervention for various medical and mental health issues. This study focused on four primary objectives. The first objective was to reconnect empirical research and clinical applications of mindfulness with original Buddhist theory and practice. The second objective was to make accessible the major findings, controversies, and developments in our understanding of mindfulness meditation, including its causal mechanisms, over the past 50 years of research. The third objective was to distinguish the effects of mindfulness meditation from other meditation techniques such as concentration forms of meditation and from other psychotherapeutic techniques such as free association. The fourth objective was to determine the efficacy of mindfulness meditation as it has been applied to various disorders in medical and clinical context. The intended audience of this study includes professionals interested in both expanding their therapeutic repertoire and interested in the current empirical findings regarding meditation; and the public, who could benefit from having a greater knowledge about the nature and effects of alternative and integrative approaches that have grown in visibility in the mainstream culture.

CHAPTER 2: APPROACH AND METHOD The Integrative Literature Review Method The present study utilized the Integrative Literature Review (ILR) method, in order to summarize the accumulated state of knowledge concerning the relation(s) of interest and to highlight important issues that research has left unresolved" (Creswell, 1994, p. 22). An ILR brings readers up-to-date on the state of the knowledge on the issue and suggests areas that need more research (Webster & Watson, 2002). According to Tarraco (2005), the integrative literature review is a form of research that reviews, critiques, and synthesizes representative literature on a topic in an integrated way such that new frameworks and perspectives on the topic are generated (p. 356). This expectation that literature reviews provide new frameworks or ways of conceptualizing an issue is consistent with Whettens (1989) observation that the mission of a theory-development journal is to challenge and extend existing knowledge, not simply to rewrite it (p. 491). The ILR is a relatively uncommon method employed in research, and a particularly novel approach for a dissertation. To date there is not a well established format to organize an ILR as there is for other empirical methods (Webster & Watson, 2002). Tarracos (2005) report provides some initial guidelines for an ILR stateing that the method attempts to counter the misconception that integrative literature reviews are less rigorous or easier to write than other types of research articles. On the contrary, the integrative literature review is a sophisticated form of research that requires a great deal of research skill and insight. (p. 356)

An ILR is typically employed when information about a subject has broadened and matured, and requires consolidation and synthesis to bring it up-to-date, or when a subject is novel and ambiguous and requires integration from various sources to provide an initial overview (Creswell, 1994). In addition, Tarraco (2005) suggest an IRL is appropriate when contradictory evidence appears, when there is change in a trend or direction of a phenomenon and how it is reported, and when research emerges in different fields (p. 359). Based on the above factors, the following justifications are provided for the use of the ILR method in this study of mindfulness meditation. 1. Meditation has been a subject of empirical research for more than 30 years (Murphy & Donavon, 1999) with well over 1,500 published studies on the topic (Gremer et al., 2005). As a subset of this extensive investigation, mindfulness meditation has been the focus of increased attention over the last decade (Baer, 2003); and may be considered a mature subject in need of consolidation and synthesis. 2. There have been several conflicting reports in the literature concerning the effects of mindfulness, specifically, if it may be classified as a distinct state of consciousness (Holmes, Solomon, Cappo, & Greenberg, 1983), what type of brain activity it produces (Davidson et al., 2003); and, most notably, its causal mechanisms and potential for therapeutic change (Baer, 2003; Loizzo, 2000). 3. There have been significant developments in our understanding of mindfulness meditation as cross-cultural collaboration and dialogue

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between Buddhist contemplatives and scholars and Western scientists and researchers increases (B.A. Wallace, 2005, 2006). 4. Mindfulness meditation is no longer a subject confined to the fields of behavioral medicine; rather, it has expanded into the domains of clinical psychology and more recently into cognitive neuroscience. To reflect this last point, the present study examined: (a) the utility and effects of mindfulness meditation from the Buddhist perspective, (b) the neuro-psycho-biologic effects of mindfulness from a scientific perspective, and (c) the therapeutic effects and efficacy of mindfulness applied in various treatment contexts from a clinical perspective. There was thus sufficient justification to support the use of the ILR method for the present study of mindfulness meditation. The goal of the ILR is to provide synthesis of conflicting reports, developments in understanding and research direction, and findings from various fields of inquiry. According to Tarraco (2005) who addressed the nature of this synthesis, Synthesis integrates existing ideas with new ideas to create a new formulation of the topic or issue. Synthesizing the literature means that the review weaves the streams of research together to focus on core issues rather than merely reporting previous literature. Synthesis is not a data dump. It is a creative activity that produces a new model, conceptual framework, or other unique conception informed by the authors intimate knowledge of the topic. The result of a comprehensive synthesis of literature is that new knowledge or perspective is created despite the fact that the review summarizes previous research. (p. 362) Webster and Watson (2002) indicated that once a synthesis of the literature was created, typically it culminated in one of four forms: (a) a

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new research agenda, (b) a taxonomy of constructs, (c) an alternative conceptual framework, or (d) a metatheory. The present study is an attempt to contribute to a new agenda for future research by posing questions that will stimulate interest in the origins of Buddhist psychology, an area that has gone largely unnoticed. Currently the general conceptualization of mindfulness is largely of a mind/body technique that is of benefit when integrated with other western behavioral and cognitive psychotherapies (Lau & McMain, 2005; Roemer, 2002). This study provides an alternative conceptual framework that establishes mindfulness meditation as a self-sufficient and time-tested therapeutic technique within a coherent and sophisticated psychological system.

Data Gathering Procedures The first step in gathering the literature reviewed was an electronic search of the PsychINFO and PubMed databases, after which a manual search was conducted of the reference sections of relevant articles for related theoretical publications, single case studies, clinical trials, and reviews of the literature. Reviewing the citations from the most current articles obtained through the database search allowed for the retrieval of an older body of literature. Once the literature was compiled, a staged review was conducted. A stage review consists of an initial review of abstracts, then an in-depth review of either just the methods and findings sections; or the entire report, depending on its significance to the argument (Tarraco, 2005, p. 361). 12

Other literature reviews and meta-analyses on the subject were examined first, so that I could orient myself to the scope of the literature and the major publications that were repeatedly cited when crossreferenced. The literature was organized into three main categories that constituted the subject matter of each distinct chapter: (a) Mind/body medicine and physiological effects, (b) cognitive neuroscience and brain effects, and (c) clinical psychology and therapeutic effects. Within each of these chapters an attempt was made to follow a sequence of themes: (a) historical context or perspective, (b) theoretical or philosophical basis, and, (c) practical applications or evidence. Key Words and Search Terms Key words and search terms included: meditation, concentration, mindfulness meditation, Mindfulness-Based Stress Reduction (MBSR), Mindfulness-Based Cognitive Therapy (MBCT), Dialectical Behavior Therapy (DBT), Attentional Control Training (ACT), insight meditation, Buddhist meditation, vipassana, and mind/body medicine. Searches for these terms were conducted individually and then combined with terms such as therapy, psychotherapy, and treatment. To narrow the focus of the review, studies involving Zen meditation, zazen, Tibetan meditation, tantric meditation, visualization, Transcendental Meditation (TM), relaxation, relaxation response, guided imagery, yoga, Relapse Prevention (RP) and progressive muscle relaxation were excluded unless required to make comparative arguments. Searches were conducted for studies examining the effects of mindfulness meditation on adult physiology, neurochemistry, brain 13

function, and biology as well as cognitive, affective, and behavioral processes. The present study further reviewed the history of meditation research in the United States, examining data from 1950 to 2006. Books, presentations, dissertations, and other scholarly materials were all considered if they matched the inclusion criteria. Buddhist Texts A number of primary Buddhist texts (sutta) and secondary commentaries were used to provide an understanding of the application and effects of mindfulness meditation as espoused in its originating context. To narrow the focus of Buddhist literature, mostly primary textual resources from the classical school of Buddhism (Theravada) represented in the Pali Canon, were included. Linguistic translations of primary Buddhist texts were beyond my scope of training and ability; therefore, the English versions of several significant texts were utilized. An online database (Access to Insight) of Pali texts translated largely by Thanissaro Bhikhu was utilized for this literature search. Names of Pali texts were typically translated and italicized and an abbreviated form was placed in parenthesis. A list of abbreviations is included in the appendix. Throughout the study the original Pali and Sanskrit (Skr) terms were translated, and the original italicized and placed in parenthesis in order to provide scholars with a reference for terms for their own translation. A glossary of Buddhist terms is also included in the appendix of the dissertation. Additional sources, such as articles, books, and presentations, pertaining exclusively to mindfulness and insight meditation were 14

included to supplement primary texts. Examining the reference sections of major works on mindfulness meditation led to a sufficient pool of credible authors on the subject. Organization of the Study Chapter 3 examines the theory and practice of mindfulness meditation as it is presented in various Buddhist sources. There are only a limited number of empirical studies (Banadonna, 2003; D. Brown, 1986; D. Brown & Engler, 1986; Campos, 2002; Goleman, 1976; Hirst, 2003; Miller, 1999; Wilber, Engler, & D. Brown, 1986) that have explored the utilization and benefits of mindfulness as described in traditional Buddhist psychology. The tendency is for researchers to extrapolate meditation techniques from their contextual basis in the so-called prescientific systems of Asia, and integrate them into their own Euro-American health disciplines. This extrapolation increases the risk of key components of the practice being lost in transition and translation (Fields, 1992; Loizzo & Blackhall, 1998). The process of reductionism and extraction is a symptom embedded within a more disparaging worldview of Eurocentric imperialism and materialism (Weber, 2001), which repudiates the mutual exchange of ideas, denies the possibility of genuine cross-cultural comparison, and stifles the potentially enriching collaborative research between two divergent yet equally viable traditions (Loizzo, 1995, 2001, 2006a; Rubin, 1996; Thurman, 1998). The present study, as has been proposed by Loizzo and Blackhall (1998), attempts to assess what the

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Buddhist spiritual tradition offers by respecting its integrity and viewing it as a coherent system. Chapter 4 begins with history of the Buddha and his teachings. Then the Buddhist psychological diagnosis of suffering, its etiology, its prognosis, and its treatment, as formulated in the Four Noble Truths framework, is reviewed. The three unconscious impulses, attachment, aversion, and delusion, which produce suffering; and the three higher trainings (adhisiksya), ethics, meditation, and wisdom, which promote cure, are examined and explained. Finally, the therapeutic techniques of calm abiding meditation (samatha) and special insight meditation (vipassana) are discussed, in addition to their corresponding cartographies, the path of tranquility and the path of insight. These paths trace the stages of the development of consciousness as produced through each meditation technique. Chapter 5 addresses the history, physiological effects, and medical efficacy of mindfulness meditation within the discipline of mind/body medicine. First, a justification for the examination of higher states of consciousness produced by meditation is provided. This is followed by a brief historical overview of Western meditation research. Then, there is an analysis of the medical studies that focus on the physiological effects of mindfulness meditation, specifically, the relaxation response (Benson, 1975); the process of deautomatization (Deikman, 1966; Rubin, 1991); and cognitive-affective uncoupling (Kabat-Zinn, 1982). The chapter concludes by reviewing disease-specific studies, which determine the efficacy of

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mindfulness meditation-based interventions in the treatment of chronic pain, anxiety, psoriasis, and cancer. In Chapter 6, there is a review of meditation research in the field of cognitive neuroscience. Through analysis of electroencephalographic (EEG) and brain imaging studies, evidence is provided to support the fact that mindfulness meditation has a unique set of neurological characteristics that distinguish it from other states of consciousness, such as waking, rest, or sleep. Studies also demonstrate how meditation can assist psychotherapy by creating a lateral shift from left to right brain dominance, thereby providing access to affective and unconscious domains of human experience. Research is used to demonstrate that meditation activates neural plasticity by cultivating an enriched environment in the nervous system, one that activates growth and repair of the brain. Chapter 7 reviews meditation research within the discipline of clinical psychology. A brief cross-cultural comparison of Buddhism and clinical psychology will be conducted, particularly as it pertains to the prevalent notion in the literature that Buddhist mindfulness and conventional psychotherapy address different levels of ego-development. A section on the potential complications of meditation will follow, in order to highlight areas where the application of meditation is contraindicated. Last, there is a critical evaluation of various clinical outcome studies and literature reviews that determine the precise mechanisms and clinical efficacy of mindfulness-based psychotherapies,

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such Mindfulness-Based Cognitive Therapy (MBCT) and Dialectical Behavioral Therapy (DBT). Chapter 8 integrates findings from the preceding chapters into a coherent presentation of the utility, effects and benefits of mindfulness meditation. The material is organized around the concept of disidentification, which was found to be a common thread weaving insights from Buddhism, medicine, neuroscience and psychology together. The dissertation ends with a concluding chapter that provides recommendations for future study in the field of meditation research.

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CHAPTER 3: MINDFULNESS MEDITATION IN EARLY BUDDHIST PSYCHOLOGY

Origins of the Buddha and His Teachings Buddhism is a living wisdom tradition, based upon personal transformation achieved through rigorous training in self-examination and self-correction (budhisodhana) (Loizzo, 2006b). After 40 years of research, eminent Buddhist scholar Robert Thurman (1997) defined Buddhism as engaged realism. Buddhism was founded by the 5th-century Indian prince and ascetic, Siddhartha Goutama, who is known as the Buddha, meaning Awakened or Enlightened One. He was not a prophet or messianic figure; rather, he was a man who, through a radical internal revolution and direct observation of self and reality, achieved a state of consciousness free from suffering (Thurman, 1997). Due to this transformation, the Buddha systematized a set of replicable teaching methods in order for others to achieve a similar optimal psychological state. As a result, some researchers have argued that Buddhism is more appropriately conceptualized as a psychology or mind science rather than a religion, as we in the West have viewed it (Thurman, 1984). Over the last 2,500 years the Buddhas teachings (dharma) have spread throughout Asia, developing new philosophical tenets and adapting its presentation to the preexisting values and rituals of the culture it has entered (Fields, 1992). Thurman (1997) argued that the natural evolution of Buddhism continues in America and Europe today as the ancient spiritual teachings and methods interact with Western mind sciences such as medicine, 19

psychology and education. Western literature is extensive regarding the life of the Buddha and the historical and philosophical developments of Buddhism in India and Tibet (Bercholz & Kohn, 1993; Conze, 1980, 1996; Cowell, 1984; De Silva, 2000; Fields, 1992; Harvey, 2000; Keown, 1996; Powers, 1995; Robinson & Johnson, 1982; Rahula, 1975; Sopa & Hopkins, 1989; Strong, 1995; Thurman, 1984). History of the Buddha There is some disagreement as to the Buddhas dates of birth and deathRahula (1975) states that the historical Buddha lived from 563 B.C. to 483 B. C., while other scholars (Conze, 1980; Keown, 1996) postulate that he may have lived as much as a century later. The Buddha was born to the rulers of the Shakya clan, hence his appellation Shakyamuni, which means "sage of the Shakya clan. The legends that grew up around him hold that both his conception and birth were miraculous. As an infant, he was presented to an astrologer who predicted that he would become either a great king or a great spiritual teacher, and he was given the name Siddhartha ("He who achieves His Goal"). His father, evidently thinking that any contact with unpleasantness might prompt Siddhartha to seek a life of renunciation as a religious teacher, and not wanting to lose his son to such a future, protected him from the realities of life by confining him within the walls of their many seasonal palaces (Robinson & Johnson, 1982). The unpleasant truths of poverty, disease, and old age were therefore unknown to Siddhartha, who grew up surrounded by every material comfort. When he was 29, he went on four consecutive chariot 20

rides outside the palace grounds and for the first time saw an old person, a sick person, and a corpse. On the fourth trip, he saw a wandering holy man whose asceticism inspired Siddhartha to follow a similar path in search of freedom from the suffering caused by bondage to the infinite and painful cycle of birth, death, and rebirth (samasara). Because he knew his father would try to stop him, Siddhartha secretly left the palace in the middle of the night and sent all his belongings and jewelry back with his servant and horse. Siddhartha abandoned his family and their luxurious existence, and for the next 6 years lived the life of an ascetic, studying with several great masters of meditation, and attempting to conquer worldly desires by engaging in various austere yogic disciplines. Finally, as he lay close to death as the result of his regimen of fasting, he accepted a bowl of rice from a young girl; and once he had eaten, he realized that physical austerities and ecstatic states of absorptive meditation (samadhi) were not the means to achieve spiritual liberation. At a small village in northern India named Gaya, he sat all night beneath a pipal tree and meditated. After transmuting the primal human instincts of compulsion, aversion, and self-preoccupation, Siddhartha attained enlightenment and became a Buddha at the age of 35 (Robinson & Johnson, 1982). It is recorded in the Jaravagga (Jrv), the 11th chapter of the classic Buddhist collection of verses, the Dhammapada (Dhp), that upon his awakening the Buddha proclaimed, I wandered through rounds of countless births, Seeking but not finding the builder of this house. Sorrowful indeed is birth again and again. Oh, house builder! You have now been seen. You shall build the house no longer. 21

All your rafters have been broken, Your ridgepole shattered. My mind has attained to unconditional freedom. Achieved is the end of craving. (Thanissaro and Access to Insight, 1997a) For 7 weeks after his enlightenment, the Buddha sat meditating under the pipal tree; and following this period of reflection, hesitation, and doubt, he decided to teach others what he had learned, encouraging individuals to follow a path that he called the middle way. This path avoided extremes of self-indulgence and self-denial in order to penetrate the true nature of reality, which he defined as causal interdependence (pratityatsamutpada), relativity (shunyata), and liberation (nirvana). He gave his first sermon, known as the Four Noble Truths, in a deer park in Sarnath, on the outskirts of the holy city of Benares; and soon had many students. For the next 45 years, the Buddha traveled throughout northeastern India, delivering his teachings of freedom from suffering achieved through his methods of calm abiding (shamata) and special insight (vipassana). The Buddha established the worlds first monastic order, which received full patronage and support by the laity and was quickly accepted into the religiously tolerant milieu of ancient India (Fields, 1992). This allowed the monks to be exempted from their conventional social responsibilities in order to pursue a higher profession as seekers of selfknowledge and freedom (Thurman, 1998). Although the Buddha presented himself only as a teacher and not as a god or as an object of worship, it is said that he performed many miracles during his lifetime, based upon the exceptional capacities of mind that he had developed during his meditation and enlightenment (Robinson & Johnson, 1982). 22

Traditional accounts relate that he died at the age of 80 in Kushinagara, after ingesting a tainted piece of food (Keown, 1996). The Buddhas physical death is a significant component of his legacy according to the Way of the Elders (Theravada), since it emphasized the fact that he was mortal and that his body was subject to the laws of material reality. This concept was confirmed in his final words, which were recorded in the Maha-parinibbana Sutta (Mpn), and found in the 16th chapter of the Diga-Nikaya (Dn). Speaking to his assembly of monks, the Buddha said, It is the nature of all conditioned things to vanish. Strive for the goal with diligence (Thanissaro and Access to Insight, 1998). The Buddhas body was cremated and the remains distributed among his followers who enshrined them in large hemispherical burial mounds (stupas), a number of which have become important pilgrimage sites. The Buddhas sermons (sutra), monastic code of ethics (vinaya), and psychological insights (abhidharma), all of which constituent the early Buddhist doctrinal canon (tripitaka), were meticulously preserved by an oral tradition and later committed to writing in both Pali and Sanskrit languages. There are reports of monks in Burma and other Buddhist countries today who can still recite by memory the thousands of stanzas that comprise the doctrinal canon (tripitaka) (Kornfield, 1983). Teachings of the Buddha The Three Vehicles Buddhist teachings can be loosely categorized into three main divisions, also known as vehicles (yanas), each unique in its expression and aim (Thurman, 1997). The first division, known as the Lesser Vehicle 23

(Hinayana), or the Way of the Elders (Theravada) occurred within the first 500 years after the Buddhas death. This division represents the classical monastic approach aimed at personal and individual liberation. It emphasizes a spirit of renunciation from the world of dissatisfaction and rebirth (samsara), and is practiced today in Southeast Asia. The second wave of teachings, known as the Great Vehicle (Mahayana), or Messianic tradition, began roughly around the 1st-century of the Common Era. At the present time, it is predominantly practiced in East Asia. These teachings emphasize altruism, universal responsibility, and a social ethic, thereby widening the scope and aim from individual liberation to social transformation. The third wave of teaching is known as the Adamantine, or Apocalyptic Vehicle (Vajrayana), which represents the esoteric tradition of Buddhism that occurred towards the middle of the first millennium A.D. and was preserved in Tibet and other Himalayan nations. This final vehicle focuses on individual and social liberation simultaneously, while emphasizing expedient, highly refined, and often secret arts (tantras) to accomplish their aims (Powers, 1995). Despite the many philosophical schools and cultural manifestations of Buddhism, the central doctrine of the Four Noble Truths and the import of mindfulness (Skt smitrti; Pali sati) and insight (vipassana) meditation remain common threads (Robinson & Johnson, 1982). The Four Noble Truths Framework Early Buddhist psychology is based upon a central medical model adapted from ancient Indian Ayurvedic medicine known as the Four 24

Noble Truths (ariya-sacca) (Loizzo & Blackhall, 1998). The fourfold model is contained in an early Buddhist text called Setting the Wheel of Dharma in Motion (Dhammacakkappavattana Sutta) (Dcp) (Thanissaro and Access to Insight, 1993) found in the Samyutta Nikaya (Sn) of the Pali Canon. The Four Noble Truths reveal the undeniable reality of suffering (dukkha) and its causes, as well as the potential of its cessation and the means to its cessation (Nyanaponika, 1965). According to the Buddhist-oriented psychologist and author Jeffery Rubin (1985, 1991, 1996), the Four Noble Truths can be viewed as the Buddhas four-part medical model to address human suffering: (a) The first truth delineates the symptoms, (b) the second provides diagnoses, (c) the third determines the prognosis, and (d) the fourth prescribes the treatment plan. The Four Noble Truths are not pillars of faith, for they do not provide relief through intellectual understanding or pious belief. Instead, they are propositions to be acted upon, tested, and verified through ones own experience (Batchelor, 1997). First Noble Truth. The First Noble Truth defines the basic characteristic of the unenlightened human life as one of difficulty and dissatisfaction (dukkha). According to its precepts, every individual experiences sickness, pain, old age, and death repeatedly through countless rebirths. The First Noble Truth is not a pessimistic view that regards life as completely hopeless or nihilistic. Rather it begins by acknowledging and accepting mankinds predicament, and attempts to lessen the influence of self-imposed sources of distress, such as harmful behavioral habits (karma), unrealistic cognitive tendencies (samskara), and afflictive emotional reactions (klesha). The First Noble Truth teaches 25

individuals to accept those things that cannot be changed while addressing the issues that intensify their condition, thereby enabling them to enjoy life on lifes terms. Primarily it is meant to inspire renunciation, the abandonment of attachment to the world of sense craving and suffering (samsara) in favor for the pursuit of wisdom (prajna) leading to freedom (nirvana). Second Noble Truth. The Second Noble Truth traces the root of suffering to one primary cause, that of misknowledge (avidya) regarding the essence of self and phenomena; and to two secondary factors, attachment and aversion. Human beings cling to experiences that by their very nature must one day dissolve; and seek to avoid experiences that inevitably arise. Individuals are driven by instinctual impulses because they mistakenly believe that phenomena are essentially permanent, fixed, autonomous, self-sufficient, and lasting. Insatiable thirst and fear-based aversion propel people toward anguish, through a sequence of 12 interdependent factors of attitude, outlook, and behavior, variously known as causal interdependence, conditioned genesis, or dependent origination (pratityat-samupadda). Buddhist psychology systematically traces through these 12 factors for a single root causes of suffering, variously identified as fundamental ignorance, the delusion of separateness, self-alienation, the defensive self-habit, self-cherishing and the reified self-habit (atmagraha) (Loizzo 2000, 2004). According to the theory of causal interdependence, human beings control their mental and physical conditionsnot a theistic God or the laws of external nature. This view explains that it is the mind that creates 26

all suffering, and it is the mind that has the ability to restore itself to peace (Rahula, 1975). The conscious disarming of negative cognitive tendencies, afflictive emotions, and unwholesome behavior removes the fuel and extinguishes the fire of self-imposed suffering (Nyanaponika, 1965). In the same way, recent stress research has revealed that the causal sequence of events involved in the fight-flight responsenegative appraisal, adverse emotions, and sympathetic activationcan be intentionally intervened, regulated, and reversed (Appley, & Trumbull, 1986; Goldberger & Breznitz, 1982; Loizzo, 2000). As a result, Buddhist psychology shifts the blame as well as the responsibility of the human predicament away from environmental influences (physical disease and mental illness) that require external agents (i.e., doctors, therapists, medications, and/or surgery) towards internal dynamics (cognitions, emotions, and habit patterns) that require reflective analysis self-regulation and self-correction (De Silva, 2000; Loizzo, 2006b). Third Noble Truth. The Third Noble Truth posits the concept that suffering can be eradicated. It is at this point that the Buddhist medical model shifts from describing the nature and cause of suffering to describing its alleviation. The focus of the Third Noble Truth is on the elimination of compulsive behaviors (karma), unrealistic cognitive patterns (samskara), and adverse emotions (klesha) through a systematic application of behavioral discipline (sila), attentional control (samadhi), and reflective learning. These paths lead to wisdom (prajna) and optimal states of health and happiness, which lie beyond description in Western medical literature (Goleman, 1977, 1979, 1981; Loizzo, 2000; B.A. Wallace, 2005). From this 27

perspective, individuals have the capacity to achieve a state of liberation from craving and delusion known as nirvana (literally the extinction of self-imposed suffering) and traditionally considered to be the full flowering of human potential (Thurman, 1997). Once behavioral compulsivity, emotional hindrances, and mental obscurations have been removed, reality is said to have three characteristics or qualities (trilaksana): impermanence (anicca), dissatisfaction (dukkha), and the absence of enduring self-essence (anatman). Individuals who are able to first intuitively conceive, then directly perceive and finally live in accord with, the reality beyond their misperception, are capable of dispelling disappointments, despair, and even fear of death, and experiencing true happiness (U Pandita, 1991). Here, Buddhist psychology differs from conventional theory in that it offers extraordinary potential for total relief from suffering, rather than mere symptom management or psychological adjustment (De Silva, 2000). Fourth Noble Truth. The Fourth Noble Truth focuses on the path that leads to freedom from self-binding compulsivity. As part of this plan, Buddhist psychology prescribes the Eightfold Path, more eloquently simplified by Loizzo (2004) as a reeducation program of three higher trainings (adhisiksya). The curriculum involves ethical/behavioral discipline (sila), mental concentration (samadhi), and wisdom (prajna) born of experiential insight. Each of the higher trainings corresponds directly with the three divisions of doctrinal canon (tripitaka): ethics with the monastic code (vinaya), concentration with the sermons (sutra), and

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wisdom with the psychological sciences (abhidharma) (Robinson & Johnson, 1982). The premise of the three higher trainings is to counteract the three causes of suffering--desire, aversion, and misknowledge of the true nature of the self and reality. In one Buddhist formulation (Nyanaponika, 1965) hostility and aversion are counteracted by moral discipline and ethical restraint. Desire, attachment, and clinging are subdued by the tranquility of mind developed through concentrated stabilization; and the primary impulse of narcissistic self-centeredness (atmagraha) is brought under the sharp focus of meditative inquiry and logically refuted under analysis. As a result of the application of these antidotes, individuals can reconstitute their hyper-aroused and stress-addicted nervous system, adverse affective conditioning, faulty cognitions, and maladaptive behavioral repertoire, by invoking qualities such as, equanimity, humility, and altruism (Loizzo, 2004). Freedom From Suffering Selflessness. The Buddhas teaching of selflessness (anatman) is unique among major world religions, philosophies, and psychological systems (Fields, 1992). Insight into selflessness is the hallmark and necessary prerequisite of the Buddhist path to health, happiness and liberation (B.A. Wallace, 2005). Unfortunately, the concept of selflessness is often misunderstood in the West and interpreted to mean that fundamentally no self, soul, or ego exists (Epstein, 1995). What the Buddha discovered was not that no self or soul exists, rather, that no fixed, unchanging, nonrelative self exists. The Buddhas middle way teachings 29

of selflessness, avoids the two extremes of reifying a fixed self or denying that a self exists at all. This teaching defiantly opposed the two predominant worldviews in the Vedic culture of the Buddhas time, including the dogmatic and authoritarian religious proclamation of an essential unchanging soul (atman, jiva) and the materialist view of the self as matter that dissolves into nothingness after death (Robinson & Johnson, 1982). According to one Buddhist view (Thurman, 1997) the self does exist, as is a relative, insubstantial collection of aggregates (skandhas) in constant flux and change, as a descriptive use of language, and as a mere conventional designation. Watson (1998) points out that the Buddhist tradition makes a distinction between the mere self, the transactional self which functions conventionally in the world, and a fictitious self, an absolute or essential self which is to be denied. The general definition of self rests on the term I, imputed in dependence upon any and all five of the psychosomatic aggregates: material form or appearance (rupa), and feelings (vedana), perceptions (samjna), determinations (samskaras) and consciousness (vijnana). The sense of self which we experience is compromised of these five skandhas or aggregates, and it is the interplay of these rather than any permanent partless ontological entity. From the Buddhist point of view, ignorance or delusion arises when this process of selfing is grasped at as an entity and identified with, rather than experienced as an ever-changing expression of dynamic interaction. In mindful awareness [practice] we can become aware of the arising and falling, coming and going of discontinuous thoughts, perceptions, feelings and sensations which make up what we like to imagine as a single coherent and continuous self. (p. 96) In terms of selflessness, suffering may be seen as a consequence of attachment to a rigid sense of self, in which the latter is perceived as being real, solid, and unchanging over time. Liberation and happiness are the results of renouncing ones narcissistic self-cherishing and defensiveness 30

and expanding ones narrow self-identification past limited ego boundaries to include a sense of interconnectedness, cherishing and responsibility for all sentient beings (Loizzo, 2006b). It is through mindfulness and insight meditation, that practitioners are able to experience the intuitive realization of selflessness, by working through the defilements (kleshas) and fundamental misknowledge (avidya) (Nyanaponika, 1965, 1972, 1998; B.A. Wallace, 2005). Mindfulness meditation thus has the potential to enable individuals to achieve the wisdom of selflessnes and a state of liberation. A short excerpt from an early Buddhist text, the Bahiya Sutta (Bs) found in the Udana (Ud), the third book of the Kuddhanikaya (Kn), discusses the use of mindfulness meditation to avoid identification with, and reification of, the aggregates leading to freedom from suffering (nirvana). In this text, the Buddha explained to his student Bahiya that in reference to the seen, there will be only the seen. In reference to the heard, only the heard. In reference to the sensed, only the sensed. In reference to the cognized, only the cognized. That is how, Bahiya, you should train yourself [in mindfulness]. When for you there will be only the seen in reference to the seen, only the heard in reference to the heard, only the sensed in reference to the sensed, only the cognized in reference to the cognized, then, Bahiya, you will not identify with it. When you will not identify with it, you will not locate yourself within it. When you do not locate within it, you are neither here nor yonder nor between the two. This, just this, is the end of suffering. (Thanissaro and Access to Insight, 1994) Overcoming the defilements. According to the revered contemporary Burmese Buddhist meditation master U Pandita (1991), there are three types of defilements (kleshas in Skt, kilesas in Pali) that must be eradicated in order for individuals to experience freedom from suffering (nirvana): 31

The first type involves defilement of transgression and includes unwholesome and compulsive behaviors, such as killing, stealing, lying, sexual misconduct, and the taking of intoxicants. The second type of defilement involves more subtle obsessions, cognitive ruminations that disturb ones mental equilibrium by intensifying the secondary impulses of addictive clinging and repulsive aversion. When transgressional defilements become preoccupations, wishes, and fantasies, their power over individuals increases; because thoughts are much more difficult to control than behavior. The third type of defilement involves the dormant or latent tendencies that operate only at an unconscious level. Within this level exist the subtlest defilement, the root obsession or primary cause of suffering known as the habit of self-reification (atmagraha) (Thurman, 1997) or the defensive-self habit (Loizzo, 2004, 2006b). Dormant defilements manifest as addictive or repellent mental propensities and consequent harmful behavioral actions. They are deeply entrenched within a misinformed perception of self in both its grandiose narcissistic presentation as well as its hostile self-protective manifestation (Rubin, 1998). Because individuals incorrectly believe themselves to be autonomous, fixed, and permanent, they reify material reality in the same manner. In this way, they are constantly involved in desirous clinging and fearful avoiding that go against the ebb and flow of the true nature of reality (Loizzo, 2004, 2006b; B.A. Wallace, 2005).

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The Three Higher Trainings According to U Panditas (1991) cogent systemization, in order for individuals to subvert the power of the defilements, they must turn to the antidotes of the three higher trainings: If you are sincere in applying sila, samadhi, and panna, you can overcome, extinguish and give up all three kinds of kilesas. Sila puts aside the kilesas of transgression; samadhi suppresses the obsessive ones; and wisdom uproots latent or dormant kilesas that are the cause of the other two. As you practice in this way you can gain new kinds of happiness. (p. 83) Ethical Conduct (Sila). Sila is a branch of training designed to lessen the attachments that individuals have to pleasurable experiences and the avoidance they have to painful experiences. It is said that moral restraint in action, speech, and livelihood leads to genuine delight and peace of mind in a way that compulsive activity fails to provide. This is because a balanced and realistic view of reality decreases ones continual expectation and pursuit of pleasure and increases ones tolerance and acceptance towards hardship, difficulty, and loss. Ethical conduct is based on the nonharming of self and others. It is the fundamental practice that targets overt behaviors and first-level defilements of transgression in order to create a lifestyle conducive to the next set of trainings of selfreflection and meditation. Attentional Control (Samadhi). Samadhi is the second training in the system, and focuses on the internal mental defilements of unrestrained compulsion and repulsion. The development of effort as well as skills in concentration and mindfulness are used to counteract a regression towards psychologycal states of automaticity and mindlessness, which 33

have recently become a subject of clinical interest (Kirsch & Lynn, 1999). This phase of training works to reform and balance extremes in mental disposition, such as dullness and laxity, restlessness and agitation, attachment and avoidance, and clinging and hostility (B.A. Wallace, 1998, 2005a). According to U Pandita (1991) once the mind is well trained, it becomes pliable, clear, even-keeled, and blissful (sukha) in order to be utilized effectively in the last category of training, which is wisdom. Wisdom (Prajna). The Sanskrit word prajna (Pali punna) translates as wisdom and is the most essential and necessary cause of liberation (nirvana). Wisdom is achieved, not through belief, but when refined awareness (samadhi) is meditatively used to investigate, analyze, and directly realize (vipassana) the nature of the self and of phenomena. Training in the correct understanding and outlook of self and reality works to carefully deconstruct and override ones powerful misperceptions, the core of which is the aforementioned reification habit. According to U Pandita (1991), only by progressing through the meditative stages on the path of insight (to be reviewed later in this chapter), can one learn to break free from the chains of misknowledge (avidya) and be freed from the bondages of self-imposed suffering (dukkah). Buddhist Meditation Techniques and Topographies The Buddhist path of self-healing and self-correction aims at the cessation of suffering through the discursive and analytic uprooting of defensive self-habits (Loizzo, 2004, 2006a, 2006b). The primary agent of this process is bhavana, the Sanskrit term used to describe a wide range of 34

mind-body interventions used to cultivate the mind. In the West we have translated the word to mean meditation, but this has the same descriptive significance as the word sport does in the sense that there are numerous variety of disciplines. Some practices aim at pacifying the mind and quieting it from its usual state of afflictive distraction and confusion. Other meditative techniques aim at the development of clear perception of reality through the use of penetrative investigation. The Buddhist tradition prescribes a combination of both methods (Goleman, 1977, 1979). Buddhist meditation is divided into two types (B.A. Wallace, 2005): (a) the concentration type, variously known as calm-abiding, quiescence, or attentional control (Skt shamata, samadhi); and (b) the mindfulness type, also known as bare-attention, witnessing, awareness training, insight practice, or analytic insight (Skt, satipatanna, vipassana). Traditionally, there are four postures in which to practice meditation: standing, walking, lying down, and sitting. Meditation, therefore, can be incorporated into any activity and is intended to become a mode of living (McDonald, 1984). Seated meditation is the most common of these postures and is composed of seven points: (a) a stable base involving a triangle of both knees and the rear firmly planted on the ground and, with use of a cushion, a tilting of the pelvis forward to enlarge the diaphragm area; (b) the spine erect but not rigid; (c) hands placed in a specific gesture (mudra) or relaxed on the lap; (d) the neck slightly tilted forward; (e) the tongue gently rested on the roof of the mouth as not to produce excess saliva (and swallowing); (f) the eyes may be shut if one is easily distracted or slightly opened and lightly gazing at a spot about 2 feet in front if one is drowsy; 35

and, (g) gentle, unforced breathing through the nostrils. There are also a series of guidelines on how to regulate attention depending on the style of meditation (McDonald, 1984). Concentration Meditation Concentration is the common feature of all meditative practices found throughout the history of the world, such as the Hindu yoga, Jewish Kabala, Christian Gnosticism, Islamic Sufism, and indigenous forms of shamanism (Goleman, 1977). Concentration meditation focuses attention on one specific object, such as the breath, a word (mantra), phrase, prayer, mental image, physical object, or thought. Whenever the mind wanders away from this object, the meditator continually and nonjudgmentally brings his awareness back to it. Concentration elicits the relaxation response that counteracts the fight/flight stress response (Benson, 1977). Common physiological changes include decreased heart rate, blood pressure, respiration, metabolism, and muscle tension. As concentration strengthens, it is often accompanied by feelings of calmness, relaxation, and equanimity and at advanced stages invokes experiences of bliss, ecstasy, and absorption. The Buddhas instructions concerning concentration are discussed in two texts found in the Pali Canon, the Samadhi Sutta (Ss) (Thanissaro and Access to Insight, 1997b) and the Anapanasait Sutta (As) (Thanissaro and Access to Insight, 2006). The physical and psychological effects of concentration are well documented by researchers in the field (Murphy & Donovan, 1999; D. H. Shapiro & Walsh, 1984). Dunn et al. (1999) found that the health benefits attributed to 36

most concentration practices, such as decreased arousal, are shared by mindfulness, while the specific benefits of mindfulness, learning and deautomatization, cannot be replicated with concentration disciplines. This distinction is useful in addressing the misconception that all meditation practices are alike, even within the Buddhist repertoire. There are many traditional maps that describe the effect of concentration meditation on consciousness. They serve as useful guides to the inner landscape for those embarking on the meditative journey; and are the result of an ancient endeavor to systematize the diverse array of experiences that occur during meditation. These systems can be extremely valuable to Western researchers who have little knowledge of the function and nature of mind at deeper levels of consciousness. While Western maps have an outside-inside orientation, most Eastern maps, such as the subtle body (chakra) system, orient the subject from the inside-out (DeCharms, 1998). This is to assist meditative adepts in navigating their own psychic terrain in vivo during meditative practice. It is this kind of first-person empirical understanding of the depths of consciousness, as well as the technology that accesses specific parts of the nervous system, that distinguish meditative from conventional psychology (Varela & Shear, 1999). The Three Realms of Experience Buddhism provides a series of internal maps to orient meditators along a spectrum of consciousness as it is refined and developed (Metzner, 1996). The first map discussed here is the Three Realms of 37

Experience (triloka); the second refers to the eight stages along the Path of Concentration (dhyana). Both maps were recorded by the Buddhist sage Buddhagosha (1991) in his pivotal 5th-century meditation manual, The Path of Purification (Visuddhimagga) and subsequently adapted and reviewed by Loizzo (2000, 2004) and Goleman (1988), respectively. The first realm. The first realm of experience refers to waking consciousness known as the desire realm (kamaloka), the everyday world of sensual craving, addiction, afflictive emotions, and alienation, all of which are rooted in the defensive self-habit. In this realm ones consciousness is dominated by outwardly directed desire and fear-based aversion, which results in the continual experience of dissatisfaction and disappointment (dukkha). Loizzo (2000) correspond this state with the activation of the neo-cortex, also referred to as the reptilian brain. Here the individual is governed by the primitive instincts such as the pleasure principal, the will to survive and the activation of flight-flight stress response. The second realm. The second realm of experience is known as the form realm (rupaloka), and is characterized exceptional states of consciousness produces by quiescence or concentration meditation. The Visuddhimagga indicates that form realms are when an individuals consciousness becomes absorb in purified emotions (brahma viharas) such as love, joy, compassion and equanimity. One may also gain access to optimal cognitive capacities that correlate with Western notions of extra sensory perception including clairaudience, the ability to hear sounds and 38

voices at a distance; clairvoyance, the ability to see events occurring in remote places; retrocognition, the ability to recall past lives; and telepathy, the ability to know the thoughts of others. Loizzo (2000) corresponds this state to the activation of the limbic system, also known as the mammalian brain, governed by the impulse of interconnectivity, social instincts and the so-called love-growth response, which contrast with the fight-flight protective mechanism. The third realm. The third realm of experience is known as the formless realm (arupaloka), in which the ultimate heights of nondual absorptions are attained. Here subject and object, perceiver and perceived are dissolved, along with notions of time and space. Experiences in the formless realm represent the most refined and exceptional states of concentrative meditation, culminating with samadhi, and corresponding to the eighth and final stage on the path of concentration (dhyana). Loizzo (2000) compares this state to the activation of the hypothalamus and brain stem, and ephemeral experiences during deep sleep and orgasm.

The Path of Concentration Stages 1 to 4 of Concentration (dhyana). Before actual concentrative absorption commences, there is a transitional state of awareness known as the access stage. This state of consciousness is traditionally considered to be the most desirable for the practice of mindfulness meditation, because the mind is unhindered by distracting sensatory-perceptual input, while 39

still retaining the discursive analytical capacities necessary for sustained learning and growth. The first level of concentration is characterized by the relinquishing of desires and unwholesome factors (akushala), with the initial onset of the dissolution of conceptualization (vitarka) and discursive thought (vichara). This level is characterized by joyful interest (priti) and well-being (sukha). The second level of concentration is characterized by the complete coming to rest of conceptualization and discursive thought, the attainment of inner calm, and one-pointedness of mind, achieved through concentration on the object of meditation. Joyful interest and well-being continue. The third level of concentration is characterized by joy that is subverted, and replaced by equanimity; one is alert, aware and feels a sense of great wellbeing. On the fourth level of concentration, ones well-being is transcended, leaving only equanimity and wakefulness to dominate consciousness (Kohn, 1991). At this stage, the last of the dhyanas that correspond to the form realm, psychic powers may be exhibited and developed. The latter four stages of concentration are (a) the absorption of limitless space, which is beyond limited perception; (b) the absorption of limitless consciousness, which is beyond undifferentiated subjectivity; (c) the absorption of nothingness, which is complete subjective relinquishing; and, (d) the peak of cyclic existence in which no course discrimination

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exists at all, known as neither perception nor nonperception (samadhi). These last four stages correspond to the formless realm. While these increasingly subtle states of consciousness provide temporary relief from suffering, produce pleasant and altruistic emotions, and activate nondual perceptions, they are ultimately all within the realm of conditioned existence (samsara). That is to say, while the mind can achieve such advanced experiences of concentrative absorption, individuals inevitably return to the base line normal waking state of craving and dissatisfaction in the desire realm. For this reason it is essential to develop the practice of mindfulness and analytic investigation, in order to provide profound insight (prajna) and lasting transformations at the base line level of waking consciousness. This type of Buddhist cartography is useful in that it clearly identifies the higher capacities of the mind, while providing landmarks for meditators to confidently traverse the terrain of the inner landscape. Mindfulness Meditation The Pali word for mindfulness meditation satipatthana literally translates as keeping present (patthana) awareness(sati). Mindfulness is the second meditation technique in Buddhist psychology. This technique differs from concentration in the way the attention is directed. Instead of restricting attention to one object, attention is systematically expanded to encompass any physical or mental activity from moment-to-moment with an attitude of detachment and acceptance. Mindfulness encourages a more exploratory and impartial stance towards whatever mind-object presents itself in a given moment. It can be best understood at first as 41

being present without reacting, and at later stages in development as analytically investigating what is being attended to. Buddhist scholars (Sole-Leris, 1986; B.A. Wallace, 2005) have pointed out that the Buddhas entire soteriology can be condensed to the application of mindfulness mediation. In a famous sermon recorded in the Satipattanna Sutta (Sp), the Buddha is reported to have said that, This is the direct path, monks, for the purification of beings, for the overcoming of sorrow and lamentation, for overcoming pain and grief, for reaching the authentic path, for the realization of nirvananamely the four applications of mindfulness(B.A. Wallace, 2005, p. 50). At the access stage of consciousness, concentration and basic mindfulness meditation are essentially the same meditation practice because they both focus exclusively on the breath. As ones attention expands to include more contents of consciousness, mindfulness departs from concentration into distinct meditation practice.

Buddhist Instructions and Texts on Mindfulness Various traditional Buddhist instructions and texts exist on how to proceed with a mindfulness meditation practice (Bodhi, 1993; Gunaratana, 1991; Nhat Hanh, 1976; Nyanaponika, 1965, 1972, 1998; Sayadaw, 1972; Soma, 1949; U Pandita, 1991; Silananda, 1990;). Most commonly in the early Buddhist approach (Theravada) the mind is first well trained in attention control (concentration) before beginning awareness training (mindfulness) (Nyanaponika, 1965, 1972). Initially the mind is made supple, malleable, and conducive to reflection as though it were a pond 42

whose ripples had been quelled, by using concentration to overcome the five hindrances of restlessness, lethargy, sensual craving, malice, and skepticism/doubt (B.A. Wallace, 2005). Then the meditator uses skill in concentration to become absorbed in a series of sublime affective states (bramha vihara), including rapture and bliss (sukkha), loving-kindness (metta), compassion (karuna), empathetic joy (mudita) and equanimity (uppeksha), which are used to counteract the evolutionary force of the five major affective emotions (kleshas) namely: greed, hatred, envy, anger, and fear (Goldstein & Kornfield, 1987). These positive affective states prepare the mind for training in mindfulness meditation where skill in concentration is conjoined with skills of impartial observation and deconstructive analysis from which successes levels of learning and insight are achieved (Loizzo, 2000, 2006b). Though the aforementioned states of concentrative absorption and the sublime states of positive emotion have their own therapeutic value, they need not be fully actualized in order to embark on the path of insight (B.A. Wallace, 1998, 2005). The only requirement is for an individual to possess a sufficient level of attentional focus and stability of mind, both of which are known as access concentration. According to Goleman (1988), The best level for practicing mindfulness is the lowest, that of access. This is because mindfulness is applied to normal consciousness, and from the first jhana on, these normal processes cease. A level of concentration less than that of access, on the other hand, can be easily overshadowed by wandering thoughts and lapses in mindfulness. At the access level, there is a desirable balance: Perception of thought retain their usual patterns, but concentration is powerful enough to keep the meditators awareness from being diverted. . . . The moment of entry and exit from jhana are especially ripe for practicing insight. (p. 21)

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Another Buddhist approach, known as bare insight, prescribes the use of mindfulness from the outset. This technique develops the necessary skills of attentional control and refined awareness simultaneously rather than sequentially. The practice also leads to the path of insight, although it may take longer or initially require a higher degree of diligence to reach access concentration (Sole-Leris, 1986). Traditional instructions on the four foundations of mindfulness are elaborated in the Pali Canon in two main texts, the Great Frames of Reference (Maha-satipatanna Sutta) (Msp) (Thanissaro and Access to Insight, 2000) and the Frames of Reference (Satipatanna Sutta) (Sp) (Thanissaro and Access to Insight, 1995). Modern commentaries on these texts are available in The Four Foundations of Mindfulness (Silananda, 1990) and the Analysis of the Frames of Reference (Satipatanna-vibangha Sutta) (Spv) (Thanissaro and Access to Insight, 1997c). In general, one is instructed to apply mindful awareness to: the body (namely, the breath), feeling/sensation (pleasant, unpleasant, neutral), mind-state/emotions (calm, agitated), and mind-objects/consciousness (mentality/thoughts). As individuals develop their skills, they are led to detached observation that uncouples the perceptual/cognitive dimension from the emotional/affective response. This process is described as disidentification with the object of perception, be it a thought, emotion or a sensation. Once mindful observation is established, it is used for analytic insight (vipassana), wherein disidentification takes place with regards to the perception of self. Analytic insight meditation involves penetrative investigation of the reifying self-habit, fosters relearning, and leads to 44

profound and sustainable insights, hense its name insight meditation (Loizzo, 2006b; B.A. Wallace, 2005). According to U Pandita (1991) the literal translation of the word vispassana is clear seeing (vi) the modes (passana) or characteristics (trilakshana) of existence and refers to suffering, impermanence, and selflessness. The difference between mindfulness and analytic insight is an important distinction as the present study points out. Note that basic mindfulness (satipatana) involves only bare attention of mind/body events, while advanced mindfulness (typically referred to as insight meditation) involves faculties of discursive thinking, investigation, decision making, information processing, contemplation and analysis, which are not typically associated with meditation practice (Loizzo, 2000; B.A. Wallace, 2005). Mindfulness and insight are two phases in the development of the same meditation practice, which was exclusively developed by the Buddha, preserved in the classical tradition (Theravada), and developed and refined in the Social Vehicle (Mahayana) and Adamantine Vehicle (Vajrayana) (Goleman, 1988; Thurman, 1997). The early Buddhist canon of scriptures (tripitaka) is divided into three collections, the Moral Code (Vinaya-pitaka, Vp), the Discourses (Suttapitaka, Stp) and the Psychological Science (Skr Abhidharma-pitaka; Pali Abhidhamma-pitaka, Ap). The seven volumes of the Abhidhamma-pitaka, offer an extraordinarily detailed analysis of the basic natural principles that govern mental and physical processes. Whereas the Sutta-pitaka and Vinaya-pitaka lay out the practical aspects of the Buddhist path to awakening such as behavioral conduct, the Abhidhamma-pitaka provides a theoretical framework to explain the causal underpinnings of that very 45

path. For modern commentaries on the Abhidhamma one is directed to Bodhi (1993) and Nyanaponika (1998). In Abhidhamma psychology the familiar psycho-physical universe is distilled to its essence revealing an intricate web of impersonal phenomena and processes unfolding at an inconceivably rapid pace from moment-to-moment, according to precisely defined natural laws of causal interdependence (pratiyatsammutpada). The Abhidhamma details the manner in which mental phenomena are thoroughly examined, using mindfulness and analytic investigation (Thurman, 1984). The literature concerning the theory and practice of traditional Buddhist mindfulness meditation is extensive with numerous studies by Western researchers (Bucknell & Kang, 1997; Goldstein, 1994; Goldstein & Kornfield, 1987; Goleman, 1988; Loizzo, 2006b; Sole-Leris, 1986; B.A. Wallace, 1998, 2005), as well as various classical presentations by Asian Buddhist Masters (Gunaratana, 1991; Nhat Hanh, 1976; Nyanaponika, 1965, 1972, 1998; Sayadaw, 1972; Soma, 1949; U Pandita, 1991; Silananda, 1990).

The Path of Insight There are several Buddhist maps that detail the psychological developments produced by mindfulness along what is called the Path of Insight. Goleman (1988) provides a lengthy discussion of subjective realizations using an eight-stage model; U Pandita (1991) condenses this same model to four stages focusing exclusively on the eradication of particular defilements (kleshas). Sole-Leris (1986) discusses the characteristics of the advanced levels of consciousness developed by four 46

types of meditative adepts known as, the stream enterer (sotapanna), the once returner (sakadagami), the nonreturner (anagami), and the liberated saint (Skt arhat; Pali arhant) who are successively closer to achieving enlightenment. These three authors rely on Nanamolis translation of Buddhagoshas (1991) The Path of Purification (Visuddhimagga). For a contemporary and userfriendly commentary of this classic manual, one is directed to Flickstein (2001). In contrast, other Western scholars (Loizzo 2000, 2006b; Thurman, 1984) rely on De La Vallee Poussin and Pruden translation of Vasubandhus (1988) The Treasury of the Psychological Sciences (Abhidharmakoshabysham) as an alternative 5th-century Indian meditation manual. These scholars find the later text more comprehensive and refined because it traces the development of insight beyond the stages of individual liberation (Theravada) to the more generous aim of social consciousness and universal responsibility prescribed in the Social Vehicle (Mahayana). Insight Stages 1 and 2. Golemans (1988) representation of the early texts begins with the attainment of stage one, access concentration, which is characterized by attentional stability and receptive awareness. In achieving this ability, individuals find that they are not distracted by, or attached to, stimuli during meditation. In the second stage, mindfulness, one formally applies these qualities of receptivity and stability to the observation of four foci namely, body, physical sensations, mental states and mind objects. In the third stage, reflection, the first experience of insight occurs in which one gains an inference into the three characteristics of reality (trilakshana) (selflessness, impermanence, and dissatisfaction). Primary among these characteristics is an understanding 47

of selflessness (anatman), the idea that no fixed agent controls the stream of thought and that no independent, automaton is at the center of ones will and experience. According to Rahula (1975), an exhaustive analysis of the five aggregates or life systems that appear to constitute a person (Skt skhandas; Pali pancakkhandhas), including material form (rupa), sensations (vedana), perceptions (sannak), mental formations (samkhara), and consciousness (vinnana), reveals no enduring, unchanging self-referent. Similarly, according to Capra (2000), a reductive analysis of external phenomena down to the atomic nuclei level reveals no essential, permanent, nonrelative core, an insight that substantiates the ancient Buddhist notion of subjective and objective selflessness (anatman/shunyata). Insight Stage 3. Next, mindful observation reveals the temporal and continually changing nature of all thoughts, emotions, sensations, and bodily functions, which deepens ones understanding of a second characteristic of phenomena impermanence (annica). Based on these two inferences, the realization arises that an identity and world, misperceived as stable and enduring, can only bring misery, frustration and disappointment. Such an awareness constitutes the third mark of existence, dissatisfaction (dukkha), resulting from attachment to compulsive and mindless living (samsara). The insight attained at the third stage on the path is said to inspire great renunciation. Rather than a passive reconciliation to a terminal fate (nihilism), or a turning over to the will of an external power (theism), the Buddhist insight into dukkha increases the motivation and ability of individuals to detach themselves from the causes 48

and conditions that give rise to dissatisfaction and misery, and work diligently to discover the causes and conditions that constitute a life of happiness and freedom. Insight Stage 4. In the fourth stage, pseudonirvana, the clear and continued perception of the arising and passing of mental phenomena, including ones projections and misperceptions, leads to a false sense of relief. An experience of enjoyment and even celebration begins to set in because individuals believe that, by disengaging from habitual mental processes, they have achieved true cessation (nirvana). While there has been a powerful and radical breakthrough, it remains only a course inference, what U Pandita (1991) calls deductive knowledge, which leaves the primal unconscious and latent defilement prone to seeing this new view of reality as concretely and inherently real. Exacerbating the situation, a mind at this state is said to experience the ten corruptions or fetters, such as expansive and rapturous feelings, tranquility, intense devotion, energy, and happiness, which are themselves reified and become the source of attachment and clinging. It is only through working with a qualified master (guru, kalyanamitra) that the meditators realize their premature error and turn their mindfulness back on itself so that they can dissolve the more subtle defilements of attachment and reification, and progress along the path. Insight Stage 5. Once the above has been achieved, the fifth stage of realization, presents itself. Here instead of a false sense of relief, the meditator is gripped by fear. With the doors of perception thus cleansed, permitting one to see the arising, sustaining and passing of mental 49

phenomenon without attachment, the thought arises that everything is baseless and void. As Goleman (1988) states, The slightest awareness [the meditator] sees as utterly destitute of any possible satisfaction. In them there is nothing but danger. The meditator comes to feel that in all kinds of becoming there is not a single thing that he can place his hopes on or hold onto. (p. 28). Once again in consultation with the expert teacher, the meditator is asked to mindfully observe the emergence of the primal need for the security of the reified self. Fear is then seen as the by-product of remaining attached to a vulnerable self that has been debased. The three qualities of existence (trilaksana) must be revisited with deeper meditation and analysis in order to transform the fear of the selfless void into an intuitive insight; or wisdom (prajna) that perceives interconnectivity (pratityatsamutpadda) (U Pandita, 1991) and ultimately the bliss and opportunity of a fluid reality (shunyata) (Thurman, 1998). Insight Stage 6 and 7. The sixth stage, effortless insight, marks this transformation in which fear is supplanted by confidence born of experience. Meditators now achieve a natural and graceful ease of reflection that continues to reinforce their understanding of selflessness (anatman) and the middle way, which avoids clinging and aversion, pleasure and pain, enjoyment and terror. In the seventh stage, nirvana, the self-reifying habit is finally dissolved and the future causes of suffering eradicated. Whereas aspects of greed, hatred, and delusion were suppressed by the higher states of consciousness only to emerge again later during waking consciousness on the concentrative path of tranquility, on the path of insight, waking consciousness itself has been purified and transformed. What occurs with the realization of selflessness 50

and the achievement of liberation is an enduring change in personality rather than a temporary state of pleasant experiences. While cogent definitions of liberation (nirvana) are rare, Makransky (1997) stated that, precise philosophical formulations of nirvana varied between Abhidharma schools, but in its primary description, nirvana represented the cessation (nirodha-satya) of karma [actions] and klesha [defilements/afflictive emotions] that give rise to the cycle of rebirth [and suffering] (p. 28). Despite the eradication of causal conditions, enlightened beings still experience the residual effect (sopadhisesa) of their past evolutionary stream of consciousness. The analogy of a steam train is useful here, in which coal is no longer added to propel the engine, but the train remains in motion until its momentum fully ceases. Insight Stage 8. The eighth and final stage in Golemans (1988) representational map of early writings is known as complete cessation (nirodh). When the remaining residual imprints have taken their effect and become exhausted, the stream of consciousness is then bound only by the human body. According to Makransky (1997), The arhats [saints] body, and the mental component associated with it, [themselves] comprise a residuum of conditioned existence (caused by the actions and passions of past lives) that will continue to his physical death. But upon his physical death, because the root cause of future conditioned existence has been utterly removed, the arhat [saint] is said to pass into a state permanently free from further rebirth: nirupadhisesa nirvana, nirvana beyond any further residual conditioning. (p. 28) The question then arises, what happens to the consciousness of enlightened beings after death? Does it disappear when electrical impulses in the brain no longer function, as science predicts? Or does it 51

continue to abide beyond the world in an absolute and permanent realm as many religious institutions have proclaimed? The standard Buddhist middle way response avoids either answer, suggesting that such a consciousness remains in the world but is no longer bound by the conditions of samsara (Makransky, 1997). Thurman (1998) described the Buddha as an enlightened being who abandoned all ordinary roles and created a new one in which an individual lives in the world but not of the world, who connects himself and therefore others to a transcendent reality that puts the demand of relative reality into the context of the transcendence (p. 93). According to Golemans (1988) discussion of the classical Theravada source the Visuddhimagga (Buddhagosha, 1991), the purified consciousness realized in nirodh does not cease to exist after the final death (parinibbana); rather it only ceases to exist under the ordinary laws of causality that govern the realm of suffering (samsara). Goleman (1988) points out that the liberated mind developed on the path of insight is then reapplied to the concentrative path of tranquility in its eight successive levels. Combining skills in stabilization and insight into selflessness, the enlightened individual advances through, and abides indefinitely within, all three realms of existence (triloka), the desire realm, the form realm, and the formless realm, in order to be a more efficacious advocate for liberation for other sentient beings. In the messianic or Greater Vehicle tradition (Mahayana), motivated by universal compassion (mahakaruna) a Buddha is said to take rebirth in forms of its choosing and remains active in all world realms in order to 52

assist others beings in their pursuit of liberation (Patrul, 1998). According to the Mahayana view of nondual relativity (shunyata), nirvana is not conceived of as an absolute realm beyond samsara, thus the Buddha remains within the suffering world, with a purified perception that reenvisions it as sheer bliss (Thurman, 1998). With such perceptual flexibility, vast new realities and heavenly realms (pure lands) are conceived and actualized by the altruistic and creative potential of the fully enlightened Buddha (samyaksambuddha) in order to provide maximally effective environments in which to train enlightened heroes (bodhisattvas) and facilitate the development of less realized individuals who are on their path to Buddhahood (Kalu, 1997; Makransky, 1997; Patrul, 1998; P. Williams, 1989). Summary In the present chapter, it can be seen that Buddhism, contrary to popular belief, is more than an Asian religion, but a psychological tradition that offers individuals precise and sophisticated methods of selfreflection and self-correction aimed at achieving health and happiness (Loizzo, 2006b). The basis of Buddhism is grouped under the Four Noble Truths, a medical model that delineates the diagnosis, etiology, prognosis and treatment of suffering. The treatment is further subdivided into the three higher trainings (adhisiksya) of ethics, meditation, and wisdom, which collectively work to dissolve attachment, aversion and self-reification at the root of human dissatisfaction. The research has shown that the wisdom of selflessness is the most salient and indispensable notion of 53

early Buddhism, and any references to the effects and benefits of the Buddhist practice of mindfulness meditation without it are simply incomplete and insufficient. The literature and research regarding the psychological effects of mindfulness and its use in the treatment of medical conditions in the West will be addressed next.

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CHAPTER 4: MINDFULNESS MEDITATION IN MIND/BODY MEDICINE Towards a Science of Enlightenment There are currently few scientific attempts to examine the concept of enlightenment and other radical shifts in consciousness produced by meditation, although there have been some preliminary efforts particularly in the field of neuroscience (DAquili & Newberg, 1999; Ekman, Davidson, Ricard, & B.A. Wallace, 2005; Lutz, Greischar, Rawlings, Richard, & Davidson, 2004; Newberg & DAquili, 2001; Newberg et al., 2001; Tart, 2003; B.A. Wallace, 2003). Reasons vary for the lack of empirical research on these subjects. Findings from several reports (Tart, 1972, 1975; Varela & Shear 1999; Varela, Thompson, & Roach, 1991) indicate that 1. Scientists may be limited by a lack of linguistic or conceptual frameworks needed to understand advanced altered states of consciousness, as there is currently no coherent understanding of consciousness in the West. 2. Scientists holding rigidly or dogmatically to their own fundamentally materialistic (nihilistic) paradigm of reality may not consider the paradigm of prescientific, mystical, or religious traditions. 3. There are too few adept meditation practitioners willing to serve as appropriate subjects of scientific investigation as this may conflict with their values or traditions of verification.

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4. The very nature of an objective, reductionistic, or mechanistic study of consciousness may alter the subject and/or process that is being observed. 5. The current Western methods of investigation are as yet insufficient or inadequate to measure altered states of consciousness with any reliability. As a result of these and other limitations, mainstream science has typically dismissed meditation and claims of enlightenment as speculative, nonrational and as an unworthy subjects of empirical research (Loizzo & Blackhall, 1998). The Buddhist literature presents the enlightened state of consciousness as an individuals optimal evolutionary development, prescribing a highly refined curriculum and sophisticated technologies to achieve this goal. Furthermore, it views advances in states of consciousness as a phenomenon that can be reliably tested and verified by meditative experts and adepts with the use of a standardized, objective quasi-scientific method. Within the relatively neutral framework of logic in ancient India, a system of validation known as valid cognition (pramana) was employed to scrutinize the reliability of truth claims put forth by competing philosophical school. In his seminal book on the ancient Indian Buddhist logician Dharmakirti, Dryfus (1997) contends that the pramana method provides a standard of validationindependent of religious or ideological backgroundsthat is useful for assessing the reliability of mental events.

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The Buddhist epistemological method of valid cognition relies on subjective-objectivity (Thurman, 1998; B.A. Wallace, 2003) also known as first-person objectivity (Varela & Shear, 1999), which contrasts with conventional scientific objectivity because it permits and encourages the use of highly trained, sustained, and nonjudgmental subjective awareness to examine internal states and experience. B.A. Wallace (2003), a Buddhist scholar and scientist, challenged critics who discredited the Buddhist proposition of enlightenment, based on their assumption that the subject fell outside the purview of the currently accepted scientific model of consciousness. B.A. Wallace (2003), in agreement with D. Chalmers (1995), argued that to date Western science had no definitive description or comprehensive understanding of consciousness, and should therefore critically examine the extensive findings achieved by contemplatives of other traditions over the course of the millennia. B.A. Wallace (2003) also reminded skeptics that Buddhism was not a religion that relied on faith, but was an ancient spiritual tradition that aimed to understand reality and the nature of consciousness through direct observation, examination, and replication, and was thus more consistent with current scientific methods. Finally, he argued that any hypothesis, including those proposing the possibility of enlightenment or reincarnation, deserved to be critically evaluated with all empirical and rational means available, without invoking the authority of any religious texts or metaphysical principles that might bias such an investigation.

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According to B.A. Wallace (2003), scientific inquiry demands that any reality claim must be meticulously scrutinized before being dismissed, otherwise how could its validity be actually known? By remaining objective and examining all possibilities, researchers can remain consistent with the Buddhas own recommendation to come and see (Pali: ehi-passika) his teachings rather than believe them out of faith or duty. As the Buddha says in one of his discourses, As the wise test gold by burning, cutting and rubbing it, so, bhikshus [monks], should you accept my wordsafter testing them, and not merely out of respect." (Rahula, 1975, p. 9) Speaking like a scientist, His Holiness the Dalai Lama, spiritual and cultural leader of the Tibetan exiled community, made the following remarks concerning the Western scientific method and the Buddhist epistemological method: From the methodological perspective, both traditions emphasize the role of empiricism. For example, in the Buddhist investigative tradition, between the three recognized sources of knowledge, experience, reason and testimony, it is the evidence of the experience that takes precedence, with reason coming second and testimony last. This means that, in the Buddhist investigation of reality, at least in principle, empirical evidence should triumph over scriptural authority, no matter how deeply venerated a scripture may be. Even in the case of knowledge derived through reason or inference, its validity must derive ultimately from some observed facts of experience. Because of this methodological standpoint, I have often remarked to my Buddhist colleagues that the empirically verified insights of modern cosmology and astronomy must compel us now to modify, or in some cases reject, many aspects of traditional cosmology as found in ancient Buddhist texts. (Gyatso, 2005, para. 4)

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Thurman (1991) similarly argued that it would be a disservice to Western health care professionals to dismiss Buddhist psychologys claim to enlightenment, because such an examination of an alternative paradigm might help them to develop their own psychological methodology, which is still in its infancy. Furthermore, he encouraged Western researchers to suspend judgment and criticism, and to expand the limits of possibility when it came to the concept of enlightenment, as it was in his view, not so obscure or impossible. Elsewhere, Thurman (1998) pointed out that hundreds of Tibetan practitioners (yogis) in modern times, prior to the invasion of China in the 1950s, achieved this optimal state partly because of the spiritually conducive environment and teaching context that their countrys sociopolitical system provided. In agreement with B.A. Wallace (2003), Thurman (1998) encouraged researchers to maintain their unbiased scientific stance of objectivity and inquisitiveness, even if it was imbued with healthy skepticism: No matter how preposterous it may seem at first, it is necessary to acknowledge the Buddhas claim of the attainment of omniscience in enlightenment. . . . It is rarely brought to the fore nowadays, even by Buddhist writers, since this claim by a being once human is an uttermost, damnable sacrilege for traditional theists and a primary fantasy, an utter impossibility, for modern materialists [scientists]. But it is indispensable for Buddhists. A Buddha is believed to have evolved to a state of knowing everything knowable, evolving out of the states of ignorance of the limited and imperfect awareness of animals, humans and gods. Therefore the purpose of ones own life, seen as a process of infinite evolution, is to awaken such omniscient awareness within oneself, to transcend the ego centered animal condition to become a perfect Buddha. (p. 10)

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The History of Clinical Meditation Research In the United States, clinical research into meditation began approximately 50 years ago. Primarily motivated by interest in the ancient practices popular in the cultural mainstream, the medical community has sought to determine their effects and possible health benefits. At the same time, evidence-based research into meditation has not been without resistance and opposition. On one side, the spiritual community argues that an objective study of meditation forces it to be removed from its natural context (as when the meditator is hooked up to various measuring devices), thereby altering or corrupting the experience (Hirst, 2003). And on the other, there are those within the scientific community who exclusively associate meditation with religion and find it an unworthy subject for experimental research. Essentially, this debate represents more than a difference in methodological style: it represents a clash of worldviews and epistemologies (Tart, 1972). As DeCharms (1998) clearly established, there are several significant differences between Buddhist meditative psychology and Western physical science, differences which indeed make their comparison even more interesting and valuable. According to the author, the most obvious is the fact that the objective of meditation is to understand the causal mechanism (pratitya-samupadda) of human experience in order to recondition habits and achieve existential freedom (nirvana). The purpose of science is to understand the laws of physical reality in order to exercise control over external phenomena.

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A more subtle difference is revealed when comparing the way in which objectivity is treated. Physical science uses objective reductionistic analysis to describe mental processes in mechanistic terms from an external perspective. Meditative science, on the other hand, uses subjective-objectivity to describe mental processes in experiential terms from an internal perspective. As can be seen, each of these systems has its own descriptive language as well as a precise and rigorous analysis of the same mental phenomena. In meditation, the emphasis is on the determination of what is manifested internally, whereas with science often the measure is focused on external forces and pressures. Despite these differences in approach and method, the initial hesitancy and skepticism concerning the study of meditation have slowly begun to subside. This is due partially to the fact that cross-cultural research (DeCharms, 1998; Gyatso, 1997; Gyatso et al., 1991; Varela et al., 1991) reveals that both disciplines are not mutually exclusive, but are rather complementaryeach may fill in the theoretical and practical gaps that the other system ignores. The results of such findings are slowly reshaping our current scientific paradigm. According to Taylor (Murphy & Donovan, 1999) Certain changes are currently underway within the basic sciences that presage not only further evolution of the scientific method but also a change in the way science is viewed in modern culture. An unprecedented new era of interdisciplinary communication within the subfields of the natural science, a fundamental shift from physics to biology, and the cognitive neuroscience revolution have liberalized attitudes towards the study of meditation and related subjects. (p. 10)

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The earliest and most prolific research (in terms of the number of published studies) focused on the investigation of Transcendental Meditation (TM), a secular, concentrative style of mental practice introduced to the West in the late 1960s by the Vedantic teacher, Maharishi Mahesh Yogi (Hjelle, 1974). Between the 1970s and the 1990s, an extensive research initiative led by Orme-Johnson (Chalmers, Clements, Schenkluhn, & Weinless, 1989a, 1989b, 1989c; Fehr, 1977; OrmeJohnson and Farrow, 1977) at Maharishi International University produced a vast data bank of some 508 studies reporting on the physiological, psychological, sociological, and theoretical effects of TM. The five-volume report contained evidence supporting a possible hypometabolic fourth state of consciousness beyond the usual waking, dream, and deep sleep states. It also showed a reduction of medical conditions such as asthma, angina, and high blood pressure as well as an increase in personality variables such as problem solving, creativity, selfesteem, field independence, and self-actualization. Finally, the research project initiated a preliminary study on the effects of TM on psychiatric and behavioral disorders, and on biomedical and endocrinological measures (Wallace, 1970; Wallace & Benson, 1972; Wallace, Benson, & Wilson, 1971). These preliminary findings on TM were then followed up by another major research initiative headed by Herbert Benson (1972, 1975) a cardiologist at Harvard Medical School, who later broke new ground by investigating advanced Buddhist practices (gTummo), although he neglected to explore their philosophical underpinning (Benson, Lehmann, 62

et al., 1982). Recorded on sight in the subzero degree Himalayas, Benson and colleagues studied Tibetan monks who, through controlling autonomic processes, were able to voluntarily generate enough body heat to produce steam and eventually dry wet sheets draped around their naked bodies. While they documented the remarkable physiological feat of the monks, Benson, Lehman, et al. (1982) failed to recognize the purpose of their practices, which was to gather and purify the passionate (sexual and aggressive) energies of the subtle body (chakra) and redirect them towards the dissolution of egocentricity, fear of death, and misperception of reality (Thurman, 1991). Nevertheless, Benson and his colleagues played a significant role in confirming the mind/body relationship by expanding Western medicine beyond limited Cartesian assumptions. By extrapolating fundamental techniques common to both TM and basic Buddhist meditation, such as quiet breath observation with a passive nonjudging attitude, Benson (1975) created a patient friendly style of practice, which he termed the relaxation response to be applied in medical settings. Clinical studies suggest that the Herbert Bensons (1975) relaxation response is effective in reversing fight-flight response patterns, lowering hypertension, headache, alcohol consumption, heart disease, and serum levels as well as being effective with psychiatric disorders such as anxiety (Benson, 1992, 1996; Benson & Wallace, 1972). Bensons (1972, 1977) main contribution is the methodologically sound nature of his research, and his publications in both medical journals and popular books have succeeded in promoting self-healing techniques as viable adjuncts to surgery and 63

pharmacology. In conjunction with Beth Israel Deaconess Medical Center and the Harvard Medical School, he launched the Mind/Body Medical Institute, a for-profit research and training program in behavioral medicine. The institute conducts research on, and provides instruction for, the medical application of meditation. Another major program in the scientific study of meditation continues under the direction of Jon Kabat-Zinn at the Center for Mindfulness in the Department of Medicine, Division of Preventative and Behavioral Medicine, at the University of Massachusetts Medical Center. Kabat-Zinns program is more explicit in its use of Buddhist mindfulness practice, in contrast to Bensons (1992) program, which employs only secularized concentrative forms of meditation. Kabat-Zinns (1982, 1990, 1994) research, like Bensons (1992, 1996), indicates that Buddhist mindfulness meditation may produce similar decreases in symptoms of heart disease, cancer, chronic pain, irritable bowl syndrome, infertility, insomnia, headache, HIV, and AIDS as well as other disorders of stress and anxiety. This is because both Bensons (1975) method and Buddhist mindfulness practice elicit the physiological relaxation response. In addition, mindfulness meditation has been found to provide health benefits, which distinguish it from other meditative disciplines (Kabat-Zinn, 1990). Kabat-Zinn and his colleagues have developed a reproducible curriculum in health education and stress reduction known as Mindfulness-Based Stress Reduction (MBSR), which has gained considerable success and is held in high repute. MBSR is utilized in over 200 affiliate centers throughout North America, and serves as a prototype 64

for subsequent developments integrating mindfulness meditation and psychotherapy, DBT (Linehan, 1993b), Acceptance and Commitment Therapy (ACT) (Hayes, Strosahl, et al., 1999), and MBCT (Segal et al., 2002).

The Physiological Effects of Mindfulness Meditation While meditation is primarily an attentional discipline designed to establish control over automatic thought patterns and negative affective responses, the physiological dimensions of the practice have received the most attention by health researchers. To date, studies determining the physiological effects of meditation far outweigh all other areas of inquiry in the medical literature. This is due primarily to the fact that, in most cases, physical measurements are accessible, easily recorded, and consistent with reductionistic Cartesian assumptions about the body. Research in this area began with an investigation of some of the more extraordinary feats of physiological control performed by advanced yogis in India during the 1920s and 1930s, as well as studies of Zen Buddhist monks in Japan during the 1960s. Das and Gastaut (1955), Anand and Chhina (1961), and Wegner and Bagchi (1961) discovered that advanced yogis practicing concentrative absorption could intentionally stop their heart beats and remain buried underground for extended periods of timein one case for 8 days (Kothari, Bordia, & Gupta, 1973). These studies involved the measuring of brain waves, heart rate, oxygen consumption, skin resistance, and blood pressure. Through extensive EEG monitoring, Kasamatsu et al. (1957) and Hirai (1960) found 65

that advanced Zen practitioners using open-focus zazen meditation maintained exceptional degrees of moment-to-moment awareness of both internal and external stimuli. These studies highlighted the difference between the two main types of meditation practice: concentration with a narrow or one-pointed attentional focus, and mindfulness with a wide or open attentional focus. Furthermore, these studies were groundbreaking because they provided the first concrete evidence that previously inconceivable, even miraculous, feats of autonomic, respiratory, and perceptual control were possible through self-regulatory strategies (Murphy & Donovan, 1999; D. H. Shapiro & Walsh, 1984). In subsequent years, research in clinical settings has been conducted to see how different physiologic functions are affected by less adept meditation practitioners. Many findings support the hypothesis that mindful meditation directly reduces every major category of the fight-orflight response, decreasing the harmful effects of stress, and possibly preventing the occurrence of major or even fatal stress-related illnesses. The present chapter discusses the most current reviews of the literature (Murphy & Donovan, 1999; D. H. Shapiro & Walsh, 1984), with particular focus on the methodologically sound studies conducted by Benson (1972, 1977), the effects of meditation on the heart, blood pressure, metabolism, respiratory system, and muscle tension. The Cardiovascular System and Disease The literature indicates that meditation has different cardiovascular effects depending on the type of practice. Those practices having an active component, such as tantric visualization, devotional chanting, and 66

concentrative styles leading to ecstatic states, tend to increase heart rate; while those practices that are passive, such as TM, Bensons relaxation, and Buddhist mindfulness, generally lead to decreased heart rate. Furthermore, some studies suggest that the decrease of beats per minute as well as the duration of the decrease is proportionate to the level of experience of the adept. For example, Wallace and Bensons (1972) study suggests that for an average clinical patient, the heart rate can decrease by as many as three to five beats per minute during TM. These results were confirmed by at least three other studies in the literature (Murphy & Donovan, 1999). Other important observations are made by Bono (1984) who found that the reduction in heart rates recorded during TM practice was greater than those resulting from quietly sitting with eyes closed. Delmonte (1984b) similarly found that for 52 subjects, heart rates were slightly lower during meditation than they were at rest. These findings contradicted those of Smith (1975) who maintained that the effects of meditation might be similarly produced by the expectation of relief or by simply sitting quietly. There is increasing agreement in the literature that meditation may have potential in relieving certain forms of cardiovascular disease, as well as reducing stressful impacts and chronic or inappropriate activations of emergency responses (Glueck & Stroble, 1975, 1984). Specifically, studies, including Benson and Wallace (1972), Benson (1976), Cooper and Aygen (1979), and Barr and Benson (1984), report significant reductions of

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hypercholesterolemia and angina pectoris through the use of relaxation and TM. Perhaps the most revealing study comes from Ornish et al. (1990) who used a prospective, randomized, controlled trial to determine whether comprehensive lifestyle changes affected coronary atherosclerosis. 28 patients were assigned to an experimental group whose varied lifestyle modifications, partially based on Indian Ayurvedic medicine, included a low-fat vegetarian diet, smoking cessation, moderate exercise, and a combination of relaxation, meditation, and yoga. The control group consisted of 20 patients who were assigned to the usual-care regimen. After one year 195 coronary artery lesions were analyzed by quantitative coronary angiography. For the experimental group, the average percentage diameter stenosis regressed from 40.0 (SD 16.9%) to 37.8 (SD 16.5%), in contrast to the usual-care group whose stenosis progressed from 42.7 (SD 15.5%) to 46.1 (SD 18.5%). According to the study, analysis of lesions greater than 50% stenosed revealed that the average percentage diameter stenosed regressed from 61.1 (8.8%) to 55.8 (11.0%) in the experimental group; and progressed from 61.7 (9.5%) to 64.4 (16.3%) in the control group. Overall, Ornish et al. (1990) reported that 82% of the experimental patients had an average change towards regression, and concluded that comprehensive lifestyle change might bring about regression of even the most severe coronary atherosclerosis after only one year, without the use of lipid-lowering drugs. This is significant because at best most conventional treatments only slow down or temporarily arrest the 68

progression of stenosis, whereas the comprehensive lifestyle treatment actually reversed stenosis in the experimental group. The fact that meditation and yoga were not isolated from other factors in the experimental group was not considered problematic by the authors because traditional Indian and Buddhist healing techniques usually involved a holistic multimodal treatment plan, which combine diet and physical exercises with mental training. From a scientific perspective, the dramatic result cannot be isolated to the effect of meditation alone. What becomes apparent from this study is the difference in approach. Conventional Western medicine focuses exclusively on mechanistically affecting the diseased portion of the body, while Indian approaches attempt to regulate various interconnected lifestyle factors underlying the disease. Ornish et al. (1990, 1998) followed up this study and supported their initial findings. The researchers brought greater awareness to the public regarding noninvasive treatment alternatives, the powerful influence of the mind and emotions to heal the body, and the importance of long term lifestyle changes (Gould et al., 1995).

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Blood Pressure and Hypertension There is strong evidence in the medical literature that meditation helps lower blood pressure in patients who are normotensive or moderately hypertensive. Murphy and Donovan (1998) indicated that as many as 19 studies replicated these findings, some of which observed significant systolic reductions in patients of 25 millimetres of mercury (mmHg) or more. They further showed that meditation decreased blood pressure as a result of the relaxation of large muscle groups pressing on the circulatory system in various parts of the body. [Meditation] might also help relax small muscles that control the blood vessels themselves; when that happens, the resulting elasticity of blood vessel walls would help reduce the pressure inside of them. (p. 50) Benson and Wallace (1972) reported on 22 hypertensive patients, whose mean blood pressure before meditation was 150/94 mmHg and who had no prior meditation experience before being taught TM. After 4 to 63 weeks of meditation practice, their mean blood pressure was reduced to 141/87 mmHg. Stone and DeLeo (1976) studied the difference in blood pressure between a treatment group of 14 hypertensive patients taught Buddhist meditation and a control group of 5 hypertensive patients. The treatment group recorded average blood pressure reductions of 9 mmHg systolic/8 mmHg diastolic while supine, and 15 mmHg systolic/10 mmHg diastolic while upright. In the control group, the mean blood pressure decrease was only 1 mmHg systolic/2mmHg diastolic while supine, and 2 mmHg systolic/0 mm diastolic while upright. Goleman and Schwartz (1976) exposed 30 experienced meditators of various orientations and a control group to a stressor film, measuring 70

skin conductance, heart rate, blood pressure, self-report, and personality scales. In comparison to the control group, the meditators heart rates and blood pressures recovered more quickly from stressful impacts, lending weight to the role meditation could play in preventative and rehabilitative medicine. As can be seen above, the effectiveness of meditation in decreasing blood pressure has been established in many studies despite the variance in the amount. Most likely this variance occurs due to different types of meditative practices, levels of experience of the practitioner, kinds of measurements, and differences in patient hypertensivity. What is also evident is that these results are dependent on compliance with the meditation regime (Delmonte, 1984a). Most studies (Frankle, 1976; Patel, 1976) confirm the fact that the physiological benefits of mindfulness require continuous practice, and decline some time after the intervention is discontinued. As discussed in the previous chapter, Buddhism advocates life long learning and lifestyle changes rather than focusing on specific treatments for disease or any sort of quick-fix approaches, such as drugs, although at times they might be necessary.

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Metabolic and Respiratory Systems Murphy and Donovan (1998) indicated in their review that in 40 studies meditation reduced oxygen consumption (in some cases up to 55%), carbon dioxide elimination (in some cases up to 50%), and respiration rate (in some cases 1 breath per minute where the average is 12 to14). Other studies suggested that meditators could suspend their breathing longer than control subjects with no apparent ill effects. These studies confirmed that meditation lowered the bodys need for energy as well as its need for oxygen to help metabolize this energy. The studies also noted that this hibernation effect occurred only in passive rather than active styles of meditative practice. An extreme example comes from Vakil (1950) report in which a middle-aged yogi was confined for more than 56 hours inside a laboratory constructed, air tight cubicle (5 x 5 x 8 feet) lined with thousands of rusty nails. The cubicle was then filled with 1, 400 gallons of water, in which the yogi remained for an additional 7 hours. The subject was then removed and found to have a normal pulse, blood pressure, and respiration rate. It should be noted again, however, that advanced autonomic controls are the consequences rather than the goals of Buddhist mind/body approaches. Muscle Tension In recent experiments (Murphy & Donovan, 1999) involving passive meditation, it was shown that there was a reduction in muscle tension, just as there was in oxygen consumption. Studies suggest that in mindfulness practice, the relaxation response lowers the need for 72

defensive armoring, while conditioned expectations of threats are consciously recognized as irrational. Such physiological relaxation of the muscular system contributes to the bodys lowered need for energy, slowing of respiration, and deactivation of stress-related hormones. Murphy and Donovan stated that as many as 15 studies showed that meditation reduces muscle tension.

The Value of Mindfulness Meditation in Medical Populations For almost 30 years, scientists studying the physiological effects of various meditation practices have come to a broad consensus that passive techniques, such as TM, Bensons relaxation and Buddhist mindfulness, reverse the negative effects of the fight-flight response. Meditation significantly reverses the sympathetic activation of nervous systems including heart rate, respiration, blood pressure, metabolism and muscle tension. This clearly establishes the effect that self-regulatory mind/body intervention has on previously considered involuntary autonomic, respiratory and perceptual functions. Given these conclusions I shall now examine how mindfulness can be effective when used in a clinical population as a treatment protocol in behavioral medicine. Chronic Pain Kabat-Zinn (1982) discussed some theoretical considerations and preliminary results pertaining to an outpatient program in behavioral medicine for chronic pain patients. Mindfulness meditation was the primary treatment in a 10-week stress reduction program to train chronic pain patients in self-regulation. Fifty-one patients who had not improved 73

with traditional health care participated in the program. The dominant pain categories were neck, shoulder, lower back, and headache. Facial pain, angina pectoris, noncoronary chest pain, and gastrointestinal (GI) pain were also represented. Data were collected from various pain, nonpain, and follow-up measures prior, during, and 7 months after the 10week program. The results of the study demonstrated that the majority of patients experienced considerable improvement in their conditions over the 10week training course in mindfulness meditation. All categories of chronic pain were included. Most of the pain reduction and affect improvement was maintained at follow-up. Furthermore, the data suggest that a program based on Buddhist meditation could be successfully integrated into a hospital setting, and that patients with chronic pain could derive considerable benefit from such a program. Kabat-Zinn (1982) concluded that, beyond the reduction in pain levels and pain related behaviors, the majority of patients evidenced attitudinal and behavioral changes which can be attributed to the practice of mindfulness meditation: an ability to observe mental events, including pain, with a sense of detachment; cognitive changes which appear directly related to the experience of detachment; and an increase awareness of oneself in relationship to others and to the world. Deep personal insights, greater patience, a new ability to relax in daily life situations and a willingness to live more in the present moment were all commonly reported, as were increased awareness of stressful situations and an improved ability to cope successfully. (p. 46) It appears that mindfulness practice facilitated an attentional attitude characterized by detached observation not present in other meditation practices. Additionally, Kabat-Zinn et al. (1985) suggest that attentional stance appeared to cause a separation (uncoupling) of the 74

physiologic/sensory dimension of pain from the cognitive/affective reaction to it. While Kabat-Zinns (1982) study showed the effectiveness of mindfulness as a treatment for chronic pain, he acknowledged some limitations to his study. These included a lack of match comparison control groups and the unreliability of self-reported measures. Finally, the self-discipline and competence needed to maintain adherence to the practice of mindfulness varied from patient-to-patient. There was also the argument that this behavioral modification offered no deep structural change, and that the health benefits could not be maintained at follow-up exceeding six months. Kabat-Zinn, Lipworth, Burney, and Sellers (1987) addressed some of these concerns in a four-year follow-up study of the MBSR program for chronic pain. Two hundred and twenty-five chronic pain patients who completed the 10-week stress reduction program over the past 5 years were studied longitudinally. Measures of follow-up status were obtained on four questionnaires, which were mailed to the study population over the course of 4 years. The results revealed that a statistically significant reduction in negative symptoms was maintained on three of the four measures. The last measure tended to return to preintervention measures, but this could have been the result of a change in the method of administration at follow-up. Seventy-two percent of responding subjects reported moderate to great improvement in pain status at 6 months, 1 year, and 3 years; while 62% and 60%, respectively, reached this level at 2 years and 4 years. A high proportion of respondents rated the program as 75

very important at all follow-up intervals, and attributed much of their improvement in pain status to the intervention of mindfulness meditation. These health benefits may have been the result of the continued practice of mindfulness long after the program. Ninety-six percent of responders reported compliance with the intervention at some level. About 76% were practicing mindfulness as much as three times a week for up 3 years after the program. In the study (Kabat-Zinn et al., 1987), it was assumed that training in a rigorous consciousness discipline, such as mindfulness meditation, in a clinical setting can optimize multiple aspects of the cognitive-behavioral learning process in chronic-pain patients and thereby promote positive change. The meditation practice evokes a new pattern of perceiving based on intentionally paying attention in a moment-to-moment mode. It is thus potentially applicable to a wide range of human activities and experiences. Mindfulness meditation can be thought of as a generalized reference-frame shift from partial awareness (an automatic pilot mode of functioning) to moment-to-moment awareness with a nonjudgmental, witnessing quality. . . . There are strong theoretical and practical reasons which suggest that a learned and intentional use of moment-to-moment awareness can have a profound effect on pain perception, the experience of suffering, and on stress reactivity. (p. 171) The follow-up findings supported the fact that mindfulness meditation in the context of stress reduction produced long-term improvement and high satisfaction in an ambulatory pain population. Similar findings regarding the use of mindfulness to increase pain tolerance were reported by Hayes, Bissett, et al. (1999). Anxiety Murphy and Donovans (1999) review of the literature identified as many as 100 studies focusing on the relationship between meditation and 76

anxiety. There was a general consensus among these reports that meditation decreased acute and chronic forms of anxiety. Loizzo (2000) was convinced that for anxiety, meditation was now the intervention of choice. Noteworthy research includes DeBerry (1982) who studied 36 elderly women (mean age 71), 83% of whom were widows, in a 20-week study designed to evaluate the effects of mindfulness on symptoms of anxiety and depression. Subjects were selected because of chronic complaints of anxiety, nervousness, tension, fatigue, insomnia, sadness, and somatic issues. Twelve subjects were randomly assigned to each of three groups: (a) an experimental meditation group; (b) an experimental meditation group, with a 10-week follow-up practice Involving meditation tapes; and, (c) a pseudorelaxation control group. The Spielberger Self-Evaluation Questionnaire and the Zung Self-Rating Depression Scale were administered before treatment, at the end of the 10week training period, and at the end of the follow-up period for group two. In comparison to the control group, the two treatment groups both manifested a significant pretreatment to posttreatment decrease in both state and trait anxiety. When the two treatment groups were compared, the group with a follow-up practice continued to show a decrease in state anxiety; while the treatment group without follow-up exhibited a return to baseline levels. Similar pretreatment to posttreatment decreases in depression were found for both treatment groups when compared to the control, and the ongoing practice group maintained these significant decreases when compared to the nonpractice group. 77

Taking into consideration the variance in meditative experiences, Davidson, Goleman, and Schwartz (1976a) studied intentional absorption and anxiety in 58 subjects assigned to four groups: (a) controls who were interested in learning but who did not practice meditation; (b) beginners who had practiced meditation for 1 month or less; (c) short-term meditators who had practiced for 1 to 24 months; and, (d) meditators who practiced for over 2 years. All subjects were given the Short Personal Experiences Questionnaire, the Tellegen Absorption Scale, and the Speilberger State-Trait Anxiety Inventory. The results indicated a reliable increase in meditative absorption, in conjunction with a decrease in trait anxiety proportionate to the length of time meditating. Vahai, Doongaji, and Jeste (1973) studied 95 outpatients diagnosed as psychoneurotic. All failed to show improvements as a result of traditional treatments. Half were randomly selected for an experimental group that was instructed in meditation and yoga exercises, while the other half, acting as a control, were given pseudotreatments consisting of breathing and stretching exercises. The treatment involved one hour of practice per day for 6 weeks. Both groups received the same support, reassurance, and placebo tablets. Following treatment, the experimental group shows significant mean decreases in anxiety, measured on the Taylor Manifest Anxiety Scale. The control group exhibited no significant change on this scale. Overall, 74% of the experimental group was judged to be clinically improved as a result of meditation and yoga. A pilot study on the effectiveness of MBSR as a treatment for anxiety disorder was undertaken by Kabat-Zinn et al. (1992) Twenty-two 78

study participants were screened and met criteria for generalized anxiety disorder, or panic disorder, with or without agoraphobia. The subjects then began an 8-week stress reduction program based on self-regulation through mindfulness. The results of the program were consistent with previous studies. There was a high completion rate of about 92%. After the intervention, 20 of the 22 patients who finished showed a marked improvement in coping with both anxiety and depression. This improvement was maintained at three month follow-up. According to the study, Patients who are able to identify anxious thoughts as thoughts, rather than as reality, report that this alone helps to reduce their anxiety and increase their ability to encounter anxiety-producing situations more effectively. The insight that one is not ones thoughts means that one has a potential range of responses to a given thought if one is able to identify it as such. This increase in options is associated with a feeling of control. It might be hypothesized that this a feature of a cognitive pathway explaining the clinical observations of this study. (p. 942) This study demonstrated statistically and clinically significant reductions in the symptoms of the participants. It underscored the fact that a significant component of mindfulness intervention is its emphasis on detached observation, which enables practitioners to see and respond more clearly to stressful situations rather than automatically reacting to them. It also indicated the need for further investigations on its long-term effects. J. Miller, Fletcher, and Kabat-Zinn (1995) discussed their findings in a 3 year follow-up to the mindfulness intervention in the treatment of anxiety disorder. Of the original 22 patients who participated in the 1992 study, 18 were contacted to determine the long-term effects. This follow79

up report focused on the maintenance of the originally observed improvements on all the outcome measures used 3 years previously. It also examined a much larger majority of participants in the stress reduction program who were not involved in the initial study. These findings provided strong evidence that an intensive, MBSR intervention was a clinically effective treatment for anxiety disorder. The study also showed a significant decrease in depression scores in anxious patients, suggesting that mind/body interventions could be equally effective in reducing symptoms of other mental illnesses. This finding would later serve as a rational in the development of Mindfulness-Based Cognitive Therapy for Depression (Segal et al., 2002). The J. Miller et al. (1995) study highlighted some noteworthy components of the intervention, one such feature being its orientation towards the general category of stress rather than toward a specific diagnostic entity. In this way, mindfulness was seen as not focusing on the treatment of anxiety, but rather on dealing more effectively with stress, pain, and chronic illness through self observation and the self regulation of intrapsychic and external behaviors (p. 196). The nonspecific orientation of mindfulness differed paradigmatically from conventional biomedical, psychiatric, and even behavioral medicine models, which advocated specific treatments for specific disorders. Instead, mindfulness was viewed as being focused on the nonspecific component of stress, which underlay and/or exacerbated many medical symptoms (Rabkin, 1982). In addition, as J. Miller et al. stated, the intervention is oriented toward what is right with people rather than what is wrong with them and aims to nurture and 80

strengthen innate capacities for relaxation, awareness, insight and behavioral change. The emphasis on this program is to encourage each individual to explore his or her own inner resources for growth and learning and healing, and to systematically cultivate mindfulness in all areas of daily life, including those times in which they find themselves confronting distressing symptoms and problems. (p. 197) Psoriasis These observations reiterate the potential of meditation to transform an individuals way of seeing and dealing with pain rather than attempting to change the pain itself. As this strategy is not disorderspecific, it may be applied as a treatment for, or as an adjunct to, a variety of clinical and medical issues. An example of this versatility comes from a preliminary report by Bernhard, Kristeller, and Kabat-Zinn (1988) which investigated mindfulness and visualization meditation as adjunctive therapies to phototherapy (UVB) or photochemotherapy (PUVA) in the treatment of psoriasis. This study involved 12 patients who underwent traditional phototherapy and photochemotherapy. The patients were randomized into two groups, 8 in an experimental group and 4 in a control group. The experimental group practiced guided meditations received on an audiotape while undergoing ultraviolet treatment. The ultraviolet treatment session was an ideal time to practice meditation because the patient was confined in a room for over 45 minutes during a highly stressful procedure. Results were collected at a turning point, when improvement was first detected; at a halfway point, when psoriasis was reduced by half; and at a clearing point when less than 5% of the psoriasis remained. Comparisons of the two groups showed that the turning point and the halfway point occurred significantly earlier for the experimental 81

group. Furthermore, 7 of the 8 patients in the experimental group achieved a 95% reduction of psoriasis in a mean of 19 sessions, whereas only 1 of the 4 patients in the conventional group achieved clearing in less than 40 sessions. While these results were preliminary due to the small sample size, they do merit further investigation into the potential health benefit of mindfulness as an adjunctive treatment for psoriasis. While mindfulness did not treat the psoriasis directly, it most likely had an effect on the patients relationship to the disease and its treatment, significantly increasing the recovery rate. Kabat-Zinn et al. (1998) followed up their initial mindfulness-based treatment for psoriasis study with better methodological controls and a larger sample size. 37 patients with psoriasis about to undergo UVB or PUVA were randomly assigned to one of two conditions: a mindfulness meditation-based stress reduction intervention guided by audiotaped instructions during light treatments, or a control condition consisting of the light treatments alone with no taped instructions. Psoriasis status was assessed in three ways: direct inspection by unblinded clinic nurses, direct inspection by physicians blinded to the patients study condition (tape or no tape), and blinded physician evaluation of photographs of psoriasis lesions. In a similar way to the previous experiment, four sequential indicators of skin status were monitored: a first response point, a turning point, a halfway point, and a clearing point. According to the results, for both UVB and PUVA treatments, Coxproportional hazards regression analysis showed that subjects in the tape 82

groups reached the halfway point (p = .013) and the clearing point (p = .033) significantly more rapidly than those in the no-tape group. Overall the meditators cleared at approximately four times the rate of those subjects receiving light treatment without the guided meditation tape intervention. This was consistent with rates recorded during the 1988 study. The authors concluded that a brief mindfulness meditation-based stress-reduction intervention delivered by audiotape during ultraviolet light therapy could increase the rate of resolution of psoriatic lesions in patients with psoriasis (Kabat-Zinn et al., 1998). Overall there is growing support for mind-body therapies in the treatment of various medical illnesses. A recent meta-analysis conducted by Astin, Shapiro, Eisenberg, & Forys, (2003) drew the following conclusions for the effectiveness of mind-body approaches including mindfulness meditation: We believe that the cumulative clinical evidence reviewed here lends strong support to the notion that medicine should indeed adopt a biopsychosocial rather than exclusively biologic-genetic model of health. . . . Based on the positive findings of metaanalyses and randomized controlled trials, there is strong evidence to support the incorporation of an array of mind-body approaches in the treatment of chronic lower back pain, coronary artery disease, headache, and insomnia; in preparation for surgical procedures; and in the management of a treatment and diseaserelated symptoms of cancer, arthritis, and urinary incontinence. Although we have noted several areas that future research should address, given the relatively infrequent and minimal side effects associated with such treatments and the emerging evidence that these approaches also result in significant cost savings, we believe that the integration of psychsocial-mind-body approaches, particularly in the clinical areas highlighted above, should be considered a priority for medicine. (p. 144)

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Cancer Several preliminary clinical trails reported improvements on various measures when mindfulness meditation was applied to a serious medical condition such as cancer (Carlson, Ursuliak, Goodey, Angen, & Speca, 2001; Carlson, Speca, Patel, & Goodey, 2003, 2004; Speca, Carlson, Goodey, & Angen, 2000), HIV (F.P. Robinson, Mathews, & Witek-Janusek, 2003), and fibromyalgia (Austin et al., 2003; Kaplan, Goldenberg, & Galvin-Nadeau, 1993; B. Singh, Berman, Hadhazy, & Creamer, 1998). Speca et al. (2000) conducted an initial randomized, wait-list controlled, clinical trial to determine effects of MBSR on a heterogeneous patient population with various types and stages of cancer. Patients completed the Profile of Mood States (POMS) and the Symptoms of Stress Inventory (SOSI) both before and after the intervention. Ninety patients (mean age, 51 years) completed the study. Patients' mean preintervention scores on dependent measures were equivalent between groups. After the intervention, patients in the treatment group had significantly lower scores on Total Mood Disturbance and subscales of Depression, Anxiety, Anger, and Confusion, and increased Vigor than control subjects. The treatment group also had fewer overall Symptoms of Stress; fewer Cardiopulmonary and Gastrointestinal symptoms; less Emotional Irritability, Depression, and Cognitive Disorganization; and fewer Habitual Patterns of stress. Overall reduction in Total Mood Disturbance was 65%, with a 31% reduction in Symptoms of Stress. The study was limited by the absence of a posttreatment follow-up.

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Carlson et al. (2001) examined the use of mindfulness in a cancer trial similar to Speca et al. (2000), this time including a 6-month follow up. All patients completed the POMS and the SOSI, before and after the intervention and six months later. A total of 89 patients (mean age 51) provided preintervention data. 80 patients provided postintervention data, and 54 completed the 6-month follow-up. The participant profile was consistent with the earlier study, heterogeneous with respect to type and stage of cancer. In general, patients' scores decreased significantly from before to after the intervention on the POMS and SOSI total, indicating less mood disturbance and fewer symptoms of stress, and these improvements were maintained at the 6-month follow-up. The diversity of the sample strengthened the generalizability of the findings. Limitations of the study included failure to use control group and unpredictability of the natural course of the illness. Of particular interest were the improvements on the depression, anger, and anxiety subscales, since these were the most frequently reported psychological symptoms identified by cancer patients. In their review of the literature prior to the study, Carlson et al. (2001) indicated that up to 53% of cancer patients were diagnosed with major depressive disorder and up to 30% with adjustment disorder. While the authors expected to see physiological changes as a result of meditation such as decreased sympathetic nervous system arousal, the greatest changes occurred on the cognitive subscales leading to enhanced psychological well-being (p. 119). Here again, the strength of mindful meditation is

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not in treating the cancer per se, but in its ability to help patients improve their subjective experience in relation to it. Carlson et al. (2001) also noted, that more advanced stages of cancer were associated with less mood disturbance, attributing this to patients having to confront their mortality, which earlier stage cancer patients could continue to delay and deny. The use of mindfulness meditation to deal with existential issues, and patients enhanced efficacy to face the future fear of death with peaceful equanimity were major benefits reported by patients in their program feedback. As one testimonial from the study suggests, In times of pain, when the future is too terrifying to contemplate and the past too painful to remember, I have learned to pay attention to right now. The precise moment I was in was always the only safe place for me. Each moment taken alone, was always bearable. In the exact now, we are, always, all right. . . . [Another patient reported] The meditation helped me focus on the present and reduce my fear of the future, which primarily that I would die. I have learned there are ways to live within stressful situations, events and conditions and find an island of peacefulness. (p. 120) Carlson et al. (2003) showed decreases in stress and mood disturbance, and improvements on a quality of life measure in a mixed gender, early-stage breast and prostrate cancer patient population following an 8-week MBSR intervention with pre/post design. The study was unique in that it examined immune functioning parameters. Although there were no significant changes in the overall number of lymphocytes or cell subsets, production of specific cells that inhibited cancer cell growth increased, whereas those associated with stress level and depression decreased. These results were consistent with a shift in immune profile from one associated with depressive symptoms to a more 86

normal profile. The authors suggested that mindfulness might be a promising adjunct to surgery and chemotherapy, but recommend larger full-scale controlled trails. Cohen, Warneke, Fouladi, Rodriguez, & Chaoul-Reich, (2004) waitlist controlled clinical trail examined the effectiveness of a Tibetanstyle mindfulness program for patients with lymphoma. Contrary to studies by Carlson et al. (2001, 2003, 2004) and Speca et al. (2000), the program showed no statistically significant decreases in levels of depression and anxiety. However, the experimental group recorded significantly lower sleep disturbance scores during follow-up compared with patients in the wait-list control group (5.8 vs. 8.1; p < 0.004). This included better subjective sleep quality (p< 0.02), faster sleep latency (p < 0.01), longer sleep duration (p< 0.03), and less use of sleep medications (p< 0.02). The authors proposed that patients undergoing or recently completed (within 12 months) conventional treatment could not only meet the challenges of intensive meditation program, but could also learn behavioral strategies aimed at coping with the difficulties of invasive treatment, leading to improved sleep-related outcomes.

Summary This chapter has highlighted some of the ways in which Buddhist meditation can be therapeutically beneficial as a primary treatment, or as an adjunct treatment, in behavioral medicine. The current literature indicates that mindfulness meditation enables practitioners to successfully cope with chronic pain and anxiety, as well as other stress-related 87

disorders, such as psoriasis. Furthermore, improved quality of life can be achieved for those currently involved in, or recently completing, conventional treatment for more serious medical illness such as cancer, HIV and fibromyalgia. This success of mindfulness meditation can be attributed both to the physiological changes that counteract stress as well as the perceptual retraining or cognitive-affective uncoupling aspect that reduces emotional disturbances such as depression and anxiety. The practice of mindfulness meditation involves an internal change in patients response to problems, and offers an alternative strategy of dealing with suffering. In its most dramatic application, mindfulness meditation prepares patients to meet the challenges posed by existential issues due to terminal illness. This behavioral approach harnesses the mind/body connection, which contrasts with most conventional medical approaches that aim to reduce symptoms by eliminating only the superficial causes of illness through highly invasive surgeries, treatments and medications. We now move to the neurological effects of mindfulness meditation.

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CHAPTER 5: MINDFULNESS MEDITATION IN COGNITIVE NEUROSCIENCE

Introduction The present study now proceeds to determine the effects of meditation on the brain by reviewing studies in the field of cognitive neuroscience. Electroencephalographic (EEG) studies of meditative states have been conducted for almost 50 years, but have yet to reveal a consensus understanding about the underlying neurophysiologic changes that occur as a result of such a practice. Sensory evoked potential and cognitive event-related potential assessments of meditative practice have also provided inconsistent results. Some reliable meditation-related EEG frequency effects for alpha and theta activity have been observed. Positron emission tomography (PET) and functional magnetic imaging (fMRI) studies are beginning to increase in the literature, providing more refined neuroelectric data. These studies suggest possible neural loci for meditation effects; although how and where such practice may alter the central nervous system have not yet been clearly identified. Thus far, broad and encompassing statements about the neurophysiology of meditation are misleading and premature, because it appears that different meditative techniques produce distinct brain effects (Dunn et al., 1999; Lazar et al., 2003; Lehmann et al., 2001; Lou et al., 1999, 2004; Lutz et 89

al., 2004). Some progress has been made to identify structure-function central nervous system relationships of meditative states and traits (Travis & Wallace, 1999), with changes in arousal and attentional state involved in meditation also related to drowsiness, sleep, and unconsciousness (Austin, 1999; Vaitl et al., 2005). In neuroscience, the research emphasis shifts from understanding interpersonal and subjective phenomena to the neurochemistry and physiological microprocesses that underlie them, both in illness and in health. This shift can be applied to the emerging field of meditation research because it provides a language relevant to Western science, a language by which clinicians and researchers can study the benefits of ancient self-healing disciplines. For centuries, Buddhist psychology (Abhidharma) has meticulously accounted for a variety of mental experiences that occur during meditation from the inside out. Now, with the use of neuroscientific techniques, it is possible to account for the same processes from the outside in. The power of noninvasive technologies has made it possible to investigate the nature of cognition and emotion in the brain, and to explore the interfaces between mind, brain, and body. Such an exploration has the potential to explain the implications of particular forms of meditative practices, including mindfulness, for modulating and regulating biological pathways. In this way, clinicians can learn how to enhance homeostatic processes and extend the reach of mind and body in 90

ways that promote rehabilitation and healing as well as greater overall health and well-being. As reviewed in the last chapter, numerous studies have documented peripheral autonomic changes associated with meditation practice, such as heart rate, respiration, and muscle tension; but, our inability to directly observe brain activity has limited understanding. In the last few decades however, efforts have been underway to define the neurological effects of meditation, including distinctions in brain effects produced by various forms of practice as well as distinctions between altered and normal states of consciousness (Davidson, 1976, 1994, 2000; Tart, 1975). Recent studies (Davidson et al., 2003; Lutz et al., 2004) showed that, when cultivated over time, meditation resulted in stable brain patterns and changes previously undocumented, suggesting a potential for the systematic development of positive neuroplastic modifications through such a practice. These investigations offer opportunities for understanding the basic unifying mechanisms that underlie awareness as well as the capacity for effective adaptation to stress (Loizzo, 2000; Rabkin, 1982). This chapter reviews studies that focused on the neurological effects of mindfulness practice. In the literature regarding this subject, the primary question that emerges is whether or not Buddhist meditation has its own unique set of neurological characteristics, distinguishing it from rest, sleep, and higher states of consciousness produced by different meditation practices. Additionally, attention is paid to the state and trait effects of 91

meditation in general and mindfulness in particular. A second area of inquiry pertains to shifts in hemispheric dominance that result from meditation. Third, this chapter investigates how meditation can increase positive affect, reverse the long-term physiological damage caused by cumulative stress, and activate the brains natural neural plasticity. Neurological Correlates of Mindfulness Meditation EEG and Alpha Activity The EEG signal generated by alpha (8 to12 Hz) activity was first described by Berger (1929) with the demonstration that closing the eyes decreased sensory input and increased alpha power over the occipital scalp (Berger, 1929). EEG studies have used these methods to describe the neurophysiologic changes that occur in meditation. Although the neuroelectric correlates of meditative altered consciousness states are not yet firmly established, some preliminary data suggests meditation increases in theta and alpha band power and decreases in overall frequency (Andresen, 2000; Davidson, 1976; Delmonte, 1984b; Fenwick, 1987; Schuman, 1980; D. H. Shapiro, 1980; D. H. Shapiro & Walsh, 1984; West, 1979, 1980a; Woolfolk, 1975). A highly controversial study by Holmes et al., (1983) investigated the arousal-reducing effects of meditation in comparison to simple rest. Using a strict methodology involving experimental control, the authors found that both meditation and rest resulted in decreased arousal; but, contrary to their initial expectation, meditation did not produce greater reductions in arousal than rest. According to Holmes et al. (1983), this

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finding brought into question the potential relevance of meditation altogether. Based on EEG monitoring there is an extensive body of neurological evidence cited by Delmonte (1984b) and West (1980a) that demonstrated similar brain patterns during rest and meditation. Murphy and Donovans (1998) review included as many as 30 studies, reporting that meditation and rest involved a similar increase in alpha activity. These slow, high amplitude brain waves, extending to anterior channels and ranging in frequency from 8 to 13 cycles per second, appeared when the subject began to feel drowsy, around stage one and two before the onset of sleep. The fact that meditation and rest caused drowsiness and resulted in similar neurological effects supported Holmes et al. (1983) findings that they decreased arousal in much the same way. The results of the study by Holmes et al. (1983) were received with much criticism, particularly by those researchers who, according to their own investigations, endorsed the use of meditation. Several years later Holmes (1987) reevaluated his findings in light of the concerns raised by his colleagues (Benson & Friedman, 1985; Shapiro, 1985; Suler, 1985; West, 1985), and published them as a chapter in the Psychology of Meditation (West, 1987). Among the most significant and convincing criticisms were those made by Suler (1985) who cautioned Holmes not to throw the psychological effects out with the physiological effects. Furthermore, Suler (1985) pointed out that if it was correct that meditation did not affect somatic activity [more than rest], let us be careful to avoid conclusions that its effectiveness in other realms must 93

therefore be restricted (p. 99). Holmes (1987) responded to this by conceding that his evidence was limited to the effects of physiological arousal. He avoided further explanation by stating that, those other effects are beyond the scope of this review (p. 99). In his concluding remarks, Holmes (1987) discussed his latest line of research involving the effects of physical fitness, and reiterated his skepticism of meditation: I can strongly recommend to persons who are interested in reducing arousal to spend their time exercising rather than meditating or resting (p. 102). In line with Sulers (1985) counter argument, it is important to demonstrate how Holmes et al. (1983) original conclusions were both misleading and inaccurate. First of all, Holmess study recorded brain activity during meditation and rest for only short periods of time. At certain intervals, in terms of decreased arousal, meditation appeared to be similar to rest; but if recorded over extended periods of time, brain waves fluctuated as the meditation practitioner regulated his awareness (Davidson et al., 2003; Lazar et al., 2000). This contrasts with measurements of rest in which reduced arousal is either maintained or further decreased as deeper stages of sleep are entered. Holmess conclusions were restricted to a single meditative moment that appeared similar to rest; and was, therefore, misleading in terms of the entire process. Holmes (1987) also did not study the differences in various meditative techniques, and he made a common error when he asserted generalizations about all types of practice. As was shown in Chapter 3, 94

Buddhist meditation training uses concentration (shamata or samadhi) provisionally as a foundation practice to stabilize and quiet the mind. This effect of decreased arousal is a prerequisite mental state conducive to the integration of other types of meditative disciplines (Bucknell & Kang, 1997). As B.A. Wallace (1998) pointed out, Indo-Tibetan Buddhism regards the ordinary, untrained mind as dysfunctional insofar as it is dominated by alternating states of laxity, lethargy, and drowsiness on the one hand and excitation and attentional scattering on the other. The cultivation of quiescence [concentration] is designed to counteract these hindrances and cultivate the qualities of attentional stability and clarity, which are then applied to training in insight. (p. 12) The difference between rest and meditation is that the meditator consciously regulates and manipulates his relaxation, while the resting subject is often overcome by sleep (Davidson et al., 2003; Lou et al., 1999). It is within the therapeutic space of restful alertness that the practitioner is able to employ mindfulness meditation (satipatana) and analytic investigation (vipassana) of sensations, emotions, thoughts, and consciousness. As in free association, it is through relaxed observation that practitioners work with their own addictions, compulsions, and unrealistic viewsall of which can lead to profound and sustained transformation and trait effects. Holmess study suggests that there is no neurological difference between meditation and rest, but this is misleading because mindfulness meditators show continuous shifts in arousal over extended periods of time during which they consciously regulate a manipulate states of relaxed awareness (Davidson et al., 2003; Lazar et al., 2000; Lou et al., 1999). Furthermore, the moments when meditation does appear similar to rest has the purpose in Buddhist training for the integration of advanced 95

practices of meditative learning. This integration contrasts with most other meditative disciplines that use relaxation exclusively. While it is true that alpha power increases during meditation because of relaxation (Morse, Martin, Furst, & Dubin, 1977), it is necessary to understand the mechanisms of Buddhist meditation in order to make useful sense of the neurological data, a concept that Holmes et al. (1983) failed to perceive.

Alpha Blocking Versus Alpha Habituation There is strong neurological evidence that distinguishes concentration from mindfulness types of meditation. Das and Gastaut (1955), Bagchi and Wenger (1957, 1958), Anand and Chhina (1961) and Kasamatsu et al. (1957) were among the first to use portable EEG machines on advanced meditators of different meditation traditions practicing in their natural context. Das and Gastaut (1955) studied 7 Indian adepts and found that concentration led to decreases in alpha amplitude and increases in alpha frequency, suggesting that this practice was a consciousness altering procedure. They also detected generalized bursts of spindles of fast activity during culminating absorptive peak experiences (samadhi). Bagchi and Wegner (1958) similarly studied Indian yogis intensively practicing concentration in caves in the Himalayas. They recorded EEG measures during the meditation session while attempting to distract the yogis with crashing cymbals and flashing lights, as well as by putting their feet in cold water. They reported that in most cases the alpha rhythm was not blocked by sensory input, indicating that during 96

advanced stages of concentration the adepts were completely unaffected by external stimuli. Together with fast rhythms during samadhi, sensory withdrawal is the distinguishing neurological features of most concentrative meditation practices. These findings have continued to be supported in more recent studies. Aftanas and Golocheikine (2005) examined the neurological effects of distressing stimulus on advanced subjects practicing Sahaja yoga compared with a control group. Their data revealed that meditators have a statistically significant increase in their ability to moderate the intensity of emotional arousal. In contrast, the findings of Kasamatsu et al. (1957) described the features of zazen meditation, which is analogous to the mindfulness type of practice used exclusively in Buddhist training. Using 48 Japanese monks as subjects, the researchers recorded fast alpha activity with the frequency of 11 to12 Hz at the commencement of the meditative session. They noted that alpha activity with the eyes open was similar to activity typically seen with the eyes closed, suggesting that zazen is a less aroused state than normal waking consciousness. This finding was reinforced by increased alpha amplitude and decreased alpha frequency, mainly in the frontal and central regions of the brain. During the later course of the session, the practitioners showed greater decreases in alpha activity suggesting that zazen was similar to sleepa point these and other authors have subsequently refuted. Using click stimulation, the researchers found a block in alpha activity, which returned several moments later indicated the presence of 97

awareness and precluded sleep. Similar alpha blocking effects were found in a group of Zen monks examined by Lo, Huang, and Chang (2003). Increases in theta and alpha coherence above baseline resting wakefulness was commonly found during meditation, further differentiating meditation from drowsiness and early sleep stages (Aftanas & Golocheikine, 2003; Travis, 1991; Travis, Tecce, Arenander, & Wallace, 2002; Travis & Wallace, 1999). Increases in overall cerebral blood flow during meditation had been observed, whereas decreases were characteristic of sleep (Jevning, Fernando, & Wilson, 1989). This outcome may be related to findings of increased melatonin levels in meditators at baseline, and increased levels in meditators during sleep on nights after meditating (Harinath et al., 2004). These results combined to support subjective reports that meditation and sleep were not equivalent states (Aftanas & Golocheikine, 2001; Delmonte, 1984b; Ikemi, 1988). Another significant finding from the Kasamatsu et al. (1957) study was that the meditators showed no habituation to the click response. The alpha activity was blocked for the same length of time following repeated auditory stimulus, without habituation. In contrast to the concentrative practices that did not block alpha waves and habituate to external distractions, mindfulness blocked alpha activity indicating an acute receptivity towards sensory input. Moreover, the absence of habituation suggested a moment-to-moment alertness rather than sensory isolation. This characterized one of the main neurological differences between the narrow and exclusive foci of concentration, and the receptive and inclusive attentional focus of mindfulness. 98

The authors described zazen as involving both attentional stances simultaneously. First concentration creates a calm and undistracted state of consciousness; then mindfulness is introduced allowing receptivity to centripetal sensory inflow. Fenwick (1987) review of the original Kasamatsu and Hirai (1966) quoted them as saying, the Zen masters reported to us that they had more clearly perceived each [clicking] stimulus than in their ordinary waking state. In this state of mind one cannot be affected by either external or internal stimulus. Nevertheless he is able to respond to it. (p. 107) It was also noted that the level of attentional capacity during deep relaxation was proportionate to the meditative maturity of the practitioner, a phenomenon known as a dose response, referring to a process by which higher levels and longer durations of meditative activity produce greater results and benefits. Findings delineated in the Kasamatsu et al. (1957) study were later corroborated by Lutz et al., (2004). Both studies were significant because they demonstrated that concentration and mindfulness were different skills that could be developed just as muscle tone could be sculpted by logging hours in a gym. Concentration is characterized by decreased arousal and sensory withdrawal. If practiced exclusively, it can culminate in increased arousal and ecstatic states (akin to bliss and orgasm) known in the Hindu yoga and Buddhist meditative traditions as Samadhi (Bagchi & Wenger, 1957; Das & Gastaut, 1955). This practice is also common to many nonBuddhist contemplative traditions such as Hinduism Bhakti, Jewish Kabbalah, Christian Hesychasm, and Sufism among others (Goleman, 1988). Depending on the depth and strength of concentration, alpha activity will 99

fail to block, an indication that the cortex is in sensory isolation from the environment. In contrast, mindfulness meditation practice begins similarly with decreased arousal, but then results in a different set of neurological effects. In the case of zazen, the presence of theta waves indicates deep relaxation, while the blocking of alpha and theta waves represents an alert attentiveness. The latter is further distinguished by a lack of habituation to stimulus, thus indicating that the central nervous system reacts anew to each successive moment. This demonstrates that the cortex is receptive to new environmental input, even to a greater degree than in normal waking consciousness. Delmonte (1984a) speculated that yogic meditators, using narrow, focused concentration, failed to block alpha waves and habituate to external input. Zen and other Buddhist practitioners, using a more open mindfulness technique, blocked alpha waves and failed to habituate to clicking stimulation. Loizzo (2000) posited that the temporary state of relaxed alertness produced by mindfulness might become an enduring trait by rewiring brain networks through repeated practice. Preliminary longitudinal studies to evaluate enduring trait effects of Buddhist practice are under way, including the Shamata Project led by Dr. B. A. Wallace, director of the Santa Barbara Institute of Consciousness Studies and the Cultivating Emotional Balance Project led by Dr. Margaret Kemeny and Dr. Paul Ekman of the University of California at San Francisco. EEG and Theta Activity Various researchers have suggested that increased theta (4 to 8 Hz) rather than increases in alpha power during meditation might be a specific 100

state effect of meditative practice (Aftanas & Golocheikine, 2001, 2002; Anand and Chhina, 1961; Fenwick et al., 1977; Hirai, 1960; Jacobs & Lubar, 1989; Travis et al., 2002; Wallace et al., 1971). Some studies of concentration meditative practice found increases in theta to be associated with dose-response and proficiency in meditative skill (Aftanas & Golocheikine, 2001). Similarly an early study of mindfulness indicated theta increase to be characteristic of only the more advanced practitioners (Kasamatsu & Hirai, 1966). Theta power increases for meditative practice have been widely reported (Aftanas & Golocheikine, 2001; Kasamatsu & Hirai, 1966; Kasamatsu et al., 1957; Lehmann et al., 2001; Lou et al., 1999; Wallace, 1970; West, 1980). Increased frontal midline theta power during meditation also was observed (Aftanas & Golocheikine, 2002), although a similar activation occurred in nonmeditation-related studies of sustained attention (Ishii et al., 1999). Attempting to relate this frontal midline theta to the differences between meditation techniques, Pan, Zhang, and Xia (1994) examined two groups of Qi-gong practitioners: those who used a concentrative style and those who employed a mindfulness approach. Even though the level of expertise in the two groups was equal, the concentrative Qi-Gong technique produced frontal midline theta activity in practitioners, while the mindfulness form did not. Although mindfulness-based practices have been assessed with EEG less often than concentrative practices, a comparative study by Dunn et al. (1999) found that mindfulness meditation produced greater frontal theta than concentrative meditation.

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This outcome contradicted previous findings that indicated an association between frontal theta and concentrative meditation. Pan et al. (1994) also revealed that novice meditators produced global theta that was shown to be higher during resting relaxation than either of the two meditative conditions, thereby implicating drowsiness as the source of the theta activity in this study. In their study, Ishii et al. (1999) found that frontal midline theta activity was generated by anterior cingulate cortex, medial prefrontal cortex, and/or dorsolateral prefrontal cortex. This activity was correlated by Gevins, Smith, McEvoy, and Yu (1997) with attention-demanding tasks and higher levels of theta activity typically correlated with lower state and trait anxiety scores (Inanaga, 1998). Therefore, increases in frontal theta for both state and trait effects in meditation was associated with decreases in anxiety level resulting from practice (Shapiro, 1980; West, 1987). This finding might be associated with common subjective descriptions, such as peace or blissfulness, and low thought content correlated with theta burst occurrences during concentrative meditation and initial moments of basic mindfulness (Aftanas & Golocheikine, 2001; Lou et al., 1999).

Brain Laterality and Hemispheric Dominance The present section addresses the following question: In what way does meditation affect the hemispheres of the brain, and can this be used for therapeutic ends? Recent research in neuroscience (Austin, 1999; Bear, 1986; Kessin, 1986; Loizzo, 2000) have determined the different functions of the right and left hemispheres of the cerebral cortex. Strong evidence 102

indicated that the left hemisphere of a right-handed individual was largely responsible for verbal communication, logical reasoning, learning, analysis, and positive emotions. The right hemisphere was associated with intuition, visual perception, creativity, preverbal experience, negative affect, and the unconscious. There are several divergent perspectives in the literature. Some researchers held the view that meditation directly activated right hemisphere function (Davidson, 1976; Ornstein, 1971, 1972; Schwartz, 1974; West, 1987). Others asserted that meditation decreased left hemisphere activity leading to the appearance of right hemisphere dominance (Abdullah & Schucman, 1976; Ehrlichman & Wiener, 1980; Meissner & Pirot, 1983; Prince, 1978). Still others (Glueck & Strobel, 1975; Lutz et al., 2004; Westcott, 1974) pointed out that meditation increased alpha amplitude in the left hemisphere, which later spread to the right. The variation in findings reiterated the need for further experimentation and research as well as a more coherent classification of effects, according to the type of meditation practice. While there was less agreement regarding the precise process and mechanisms of hemispheric activation, there was general agreement that concentration types of meditation eventually activated the right hemisphere (Aftanas & Golocheikine, 2005). Even though the right hemisphere might be in ascendancy only during initial stages of meditation, EEG amplitude data suggested that meditation could have long-term effects on specific abilities controlled by the right hemisphere. Bennett and Trinder (1977) found that as a group, 103

meditators exhibited greater asymmetrical differences between visual and verbal tasks. Similarly, Earle (1977) found that while an arithmetic condition was significantly left lateralized from a baseline condition for a trained group of meditators, this was not true for an untrained group of controls. Greater EEG asymmetry differences between verbal and visual tasks were associated with special orientation and superior ability (Fiore, 1978). Thus, in agreement with Davidsons (1976) findings, these studies of showed that meditation might lead to greater right hemisphere-specific abilities. More recently, Loizzo (2000) pointed out that neurological effects were dependent on the type of meditation practice being studied. While concentration activated right-hemispheric dominance, Loizzo (2000) maintained that in insight meditation (full mindfulness) both sides of the brain were activated simultaneously and brought into an integrated harmony. Rather than working in a dualistic manner with each hemisphere working unilaterally, mindfulness accessed functions associated with each hemisphere. This seems plausible given the relaxed and alert state that mindfulness is designed to cultivate in order to introduce sustained analytic investigation (left hemisphere activity) of negative affect and habitual unconscious impulses (associated with the right hemisphere). Loizzo (2000) proposed that mindfulness meditation might effect a shift from left hemispheric unilateral dominance to bilateral activation. This would enable left-hemisphere functions, such as analysis and learning, to process preverbal experiences, negative affects, and other 104

unconscious phenomena associated with the right hemisphere. It was previously established that the psychotherapeutic potential of meditation was its ability to access the unconscious (Epstein, 1990a) and unveil repressed material (J. Miller, 1993). At present no neurological studies have been conducted to test this hypothesis. What relevance do these neurological findings of meditation have on Western psychotherapy? For one, they are in agreement with the traditional Indian accounts of Buddhagosha (1991) and those contemporary scholars that have examined his work (Goleman, 1988; Thurman, 1984) that mindfulness is a conscious activity that includes intuitive and direct perceptual experience of reality, rather than the intellectual, rational, and cognitive capabilities alone. Sustained mindfulness represents a shift from our ordinary hyper-reactive state to a more emotionally relaxed, perceptually receptive state. This cultivated state may be useful to the goals of psychotherapy because, for example, it can provide a nondefensive frame of mind conducive to the examination of repressed feelings and memories. More importantly, if skill in mindfulness were further developed it could eventually deepen into a sustained baseline trait of consciousness characterized as more relaxed, deautomatized, and less habituated (B.A. Wallace, 2005).

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PET, fMRI, and EEG Studies Two relatively new neuroimaging techniques, positron emission tomography (PET) and functional magnetic resonance imaging (fMRI), provide distinct tools for researchers exploring activity within the brain. PET can follow differences in brain activity over a course of a meditative session, while fMRI can examine more thoroughly a single moment of meditative experience, even including the release of neurotransmitters such as dopamine. Gremer et al. (2005) contrasted these techniques with the much older electroencephalogram (EEG) capability, stating, EEG signals have millisecond resolution but poor spatial resolution. These images give the scientist only a general brain region in which the activity is occurring and cannot reliably detect activity from deep subcortical structures such as the amygdala and or hippocampus. The use of EEG has allowed scientists to identify dynamic changes in brain activity during meditation in a way that reflects the types of activity that are occurring (alpha, gamma, or beta waves) not just the regions that are active. Furthermore, EEG has an advantage over PET and fMRI, in that it allows researchers to assess brain activity in a quiet and relatively naturalistic setting. (p. 234) Lazar et al. (2000) used fMRI to monitor effects of Kundalini yoga (a concentration practice) and found that activity steadily increased in brain regions involved in attention and physiological modulation while activity decreased in the sensory cortex. This supported subjective accounts that concentration style meditation involved a withdrawal of attention from external and sensory stimulation. In a study involving PET of another concentrative practice known as Yoga Nidra, Lou et al. (1999) found decreases in brain regions involved in executive control, emotional processing, and motor planning. In their follow-up study (Kjaer et al., 2002), these same researchers found 106

increased levels of dopamine released in the striatum, which was consistent with subjective accounts of feelings of relaxation and decreased arousal. In another study of concentration meditators, Newberg et al. (2001) found decreases in parietal lobe activity, a region involved in sensory integration and maneuvering in space. Decreased activity in this region was consistent with subjective reports of meditative experience of the higher jhanas of the formless realm, and of mystical accounts of out-ofbody experiences and loss of time and space. In contrast to these studies examining the effects of concentration meditation (CM), Davidson et al. (2003) conducted a randomized, controlled trial on the effects of MBSR on brain and immune function with healthy employees in a work environment. EEG data was collected at baseline, immediately after, and at 4 months post intervention. Following the 8-week mindfulness program all subjects were vaccinated with influenza vaccine. The study also differed from most other brain studies by shifting its investigative emphasis away from meditative effects during a single session to those that could be more enduring. The Davidson et al. (2003) study indicated that over a period of time, mindfulness meditators achieved greater levels of left-sided activation of anterior regions in the brain, compared to the control group. It had been previously established that activation in these regions was associated with decreased anxiety and increased positive affect (Davidson & Irwin, 1999). These findings were the first to document significant changes in anterior activation asymmetry as a function of meditation training (p. 9). The neurological benefits of mindfulness meditation 107

become clearer when viewed in combination with previous evidence (Davidson, 2000) that left-sided anterior activation increased recovery rates from stress related conditions and negative provocations. The Davidson et al. (2003) study was the first to show increases in immune function as a result of mindfulness meditation, as indicated by the rapid peak rise of antibody titers among the experimental group post vaccination. The study suggests that there is a high correlation between left-side brain activation and increased immune function. The researchers indicated that the small sample size and limited statistical data made their findings provisional and that further investigation was needed. But they did conclude that a short training program in mindfulness meditation could have important health-promoting biological and neurological effects. The study lends weight to the assertion that mindfulness meditation differs from concentration in terms of neurological effects. Furthermore, it appears that mindfulness meditation might help bridge the mind/brain divide by providing a technology that shifts mental states from stress-reactive to tranquil, and affective states from anxious to enriched and pleasurable. The authors showed that these shifts in psychological disposition influenced neurobiology by boosting immunity and rehabilitating long-term neurological degradation, thus hastening recovery from environmental challenges. According to Cahn and Polich (in press), the Davidson et al. (2003) study indicated that these outcomes may reflect the relative activation of left and right prefrontal cortices, which indexes emotional tone and motivation such that left-greater-than-right alpha power is associated with greater right frontal hemisphere activation (Coan & Allen, 2004; 108

Davidson, 1988, 2003). In this framework, appetitive and approachoriented emotional styles are characterized by a left-overright prefrontal cortical activity, whereas avoidance and withdrawaloriented styles are characterized by right-over-left prefrontal cortical dominance (Davidson, 1992; Davidson, Ekman, Saron, Senulis, & Friesen, 1990; Davidson & Irwin, 1999). Normal variation of positive versus negative affective states suggests left dominance for happier states and traits, with left-over-right frontal hemispheric dominance primarily related to the approachwithdrawal spectrum of emotion and motivation (Davidson, Jackson, & Kalin, 2000; HarmonJones, 2004; Harmon-Jones & Allen, 1998; Wheeler, Davidson, & Tomarken, 1993). In sum, meditation practice may alter the fundamental electrical balance between the cerebral hemispheres to modulate individual differences in affective experience, with additional studies warranted to assess this possibility. (p. 15) Neuroplasticity theory (A. Damasio, 1994) suggests the possibility that by cultivating positive states such as happiness (sukha) and care (karuna) overtime, they can become more firmly ensconced personality traits through repeated learning and reinforcement, which ultimately transforms neural networks in the brain (Begley, 1986; Schore, 2003; Siegel, 1999; Solms & Turnbull, 2002). The opposite findings have already been established, whereby negative character traits and adverse emotions, such as self-involvement (Graham, Scherwitz, & Brand, 1989; Scherwitz, Graham, & Ornish, 1985; Scherwitz, Graham, Grandits, Buehler, & Billings, 1986), anger (Ornish et al., 1990), and hostility (Williams, 1989), release a toxic mixture of hormones within the nervous system, including cortisol and adrenocorticotropin, which over time has been found to impinge neural growth (Sapolsky, 2003), decrease cortical volume (Rosenzweig & Bennett, 1996) and correlate highly with heart disease (Ornish et al., 1998; Williams et al., 1999) depression (Teasdale et al., 2000), and death (Lee, Ogle, & Sapolsky, 2002; Sapolsky, 1998, 1999). 109

Lutz et al. (2004) also suggested that increased attention and positive affect were skills that could be acquired through mental training. They examined the neurological effects of meditation produced by two groups with varying levels of meditative experience. Compared to novice meditators, the highly trained Tibetan Buddhist meditators, who had acquired over 10,000 hours in meditation, had markedly higher amplitude, and long-range global gamma synchrony in bilateral frontal and parietal/temporal regions. An increase in gamma synchrony was also observed in baseline measurements (before meditation) that became enhanced and more global during meditation in the trained Tibetan meditators. Gamma-band frequencies were found to correspond with attention, working memory, learning, conscious perception, and the dreaming state (Fries, Reynolds, Rorie, & Desimone, 2001). The neurological changes produced by the expert meditators added further support of an electrophysiological correlate of consciousness. The fact that trained Tibetan meditators had baseline increases in gamma synchrony and amplitude suggested long-term changes in their brains as a result of years of meditation practice. One might speculate that as a result of meditative-induced development in specific brain regions, these monks functioned at a more highly conscious baseline state, and achieved even greater intensity of conscious awareness during meditation. The authors (Lutz et al., 2004) refuted the concept that these neurological effects were caused by preexisting differences in the sample. Their correlation analysis revealed that hours of practice significantly predicted gamma-band synchronization not age, culture of origin, or demographics. Once 110

again, the study confirmed a rate-proportionate (dose-response) characteristic of meditation. A particularly astonishing finding highlighted the study. While abiding in state of loving kindness for all beings during a meditation practice referred to as nonreferential compassion (dmigs med snying rje, in Tibetan), the Tibetan monks showed the highest amplitude gamma activity ever reported in a nonpathological participant. In a recent press interview, one of the researchers described the readouts of a monks level of brain activity and state of happiness to be right off the curve (Savory, 2004). Taking advantage of fMRI, researchers identified specific regions that were active during compassion meditation. In almost every case, the enhanced activity was greater in the brains of the monks than in those of the novices. Increased activity in the left prefrontal cortex, which is the seat of positive emotions such as happiness, joy, and enthusiasm, was simultaneously observed with decreased activity in the right prefrontal, the seat of negative emotions, anxiety, and sadness (Goleman, 2003a, 2003b). A sprawling circuit that switches on at the sight of suffering also showed greater activity in the monks. So did regions responsible for planned movement, as if the brains of the monks were primed to respond to the distress of others. Again the neurological effects of distinct practices must be stressed. The nonreferential compassion practice of this particular Tibetan Buddhist monk under observation incorporated skill in attentional control (concentration) to maintain the centrality of theme of

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compassion, yet retained an alert receptivity (mindfulness) to the plight of others. The implications of a feedback loop in which brain matter and function can be altered through intention and reinforced through meditative training are extremely significant. Equally important is the shift in the paradigm of the health sciences to include concepts of positive affect and well-being, rather than solely focusing upon disease and pathology. This paradigm shift is being pioneered in part by Richard Davidson (1976, 1988, 1992, 1994, 2000, 2003; Davidson & Goleman, 1977; Davidson, Ekman, Saron, Senulis, & Friesen, 1990) as well as various other researchers (Ekman et al., 2005; Urry et al., 2004) who are promoting concepts, such as flourishing, resilience, and well-being in response to their findings that meditation can help cultivate positive human qualities. Davidson and colleagues of the Labratory for Affective Neuroscience at the University of Wisconsin-Madison, have been awarded a $15 million grant to study the positive effects of meditation using Tibetan Buddhist adepts as their sample (Savoy, 2004). In a recent interview (Savory, 2004) Davidson stated that the monks, we believe, are the Olympic athletes of certain kinds of mental training, these are individuals who have spent years in practice. To recruit individuals who have undergone more than 10,000 hours of training of their mind is not an easy task and there aren't that many of these individuals on the planet. (para. 22). It is an extremely rare and fortunate opportunity to examine the brains of experts who may shed light on the outermost ranges of positive human potential. In Savorys (2004) interview, Davidson stated that, "Our work has been fundamentally focused on what the brain mechanisms are 112

that underlie these emotional qualities and how these brain mechanisms might change as a consequence of certain kinds of training (para. 36). Davidson refuted the view that happiness was a byproduct of fortunate environmental circumstance and proposed that rather than thinking about qualities like happiness as a trait we should think about them as a skill, not unlike a motor skill, like bicycle riding or skiing. These are skills that can be trained. I think it is just unambiguously the case that happiness is not a luxury for our culture but it is a necessity. (Savory, 2004, para. 30) With incidents of stress-induced, so-called diseases of civilization on the rise, Davidson concluded the interview suggesting that, "the human and economic cost of psychiatric disorder in Western industrialized countries is dramatic, and to the extent that cultivating happiness reduces that suffering, it is fundamentally important" (Savory, 2004, para. 28). Neuroplasticity In recent years, research on the mechanisms of stress has led to a new understanding of the origins of mental illness (Appley & Trumbull, 1986; Fawcett, 1992; Rabkin, 1982; Sapolsky, 1998, 1999; Schmidt et al., 1997). Loizzo (2000) reported that the triphasic sequence of events observed in the fight-flight response to stress included unrealistic appraisal, fear-based cognition, adverse affect, and hypothalamicpituitary-adrenal activation. There was strong evidence implicating stress in the production of long-term neurological consequence if the triphasic sequence continued to go unchecked. Repeated activation of this triphasic stress sequence resulted in decreased neurogenesis, long-term degradation of neural tissue, and decreased cortical volume. It also might be involved in the development of psychological trauma, anxiety, and 113

mood disorders (Sheline, Wang, & Gado, 1996; Yehuda, 1997). The allostasis model conceived in mind-body research may shed light on the pathological effects of uncontrolled stress. According to Shulkin, McEwen, and Gold (1998), Allostasis means achieving stability through change, and it refers in part to the process of increased sympathetic and hypothalamic pituitary adrenal activity to promote adaptation and to reestablish homeostasis. Allostasis also highlights our ability to anticipate, adapt or cope with impending future events. . . . [W]hen allostatic systems remain active they can cause wear and tear on tissues and accelerate pathophysiology a phenomenon we have called allostatic load. . . . There are three types of allostatic load: 1) Frequent over stimulation by frequent stress, resulting in excessive hormone exposure; 2) failure to turn off allostatic responses when they are not needed or inability to habituate to the same stressor, both of which result in overexposure to stress hormones; 3) inability to turn on allostatic responses when needed, in which case other systems (e.g., inflammatory cytokines) become hyperactive and produce other types of wear and tear. (p. 220) This model helps to conceptualize the neurological processes involved in, and affected by, the exposure to stress. Two developments in cognitive neuroscience offer encouragement that there are potential solutions to the issues caused by allostatic load. First, there is evidence that the nervous system is more flexible and dynamic than was previously conceived (A. Damasio, 1994). The last century of biological and neurological researchers consistently maintained that the brain and central nervous system were largely hard-wired and rarely changed after an initial period of development (Reiser, 1984). New evidence seems to indicate the contrary, and, as Loizzo (2000) pointed out a greater dialog with neurobiology has made psychotherapy researchers aware that learning plays a formative role in the development of brain structure and function, and that its substrate neuroplasticity, is a pervasive and continuous property of neural 114

systems, rather than the exception to a rule of genetically determined hard-wiring. (p. 149) Neuroplasticity refers to structural and functional changes in the brain, which have been brought about by training and experience. The brain is the organ that is designed to change in response to experience. Neuroscience and psychological research over the past decade on this topic have burgeoned and are leading to new insights about the many ways in which the brain and behavior change in response to experience (Davidson, 1994). This basic issue is being studied at many different levels, in different species, and on different time scales. Yet all of the work invariably leads to the conclusion that the brain is not static but rather is dynamically changing and undergoes such changes throughout one's entire life (Damasio, Grabowski, Frank, Galaburda, & A. Damasio, 1994). Therefore, damage caused by allostatic load is not necessarily irreversible, as the nervous system may continue to learn, grow, change, and heal itself throughout a life span if an individual continues to receive positive stimulation and enrichment (Rosenzweig & Bennett, 1996; Swaab, 1991). Further research into meditation and the biological mechanisms of stress/emotional reactivity would provide needed substantiation for theories implicating such practice in the functional reorganization of stress-related limbic structures (Esch, Guarna, Bianchi, Zhu, & Stefano, 2004). The second encouraging development is that there is some indication as to what might provide this continued positive stimulation or enriched environment. This is where developments in meditation research and mind-body medicine may have their greatest impact (Loizzo, 115

2000). The state and traits produced by meditation may nourish the brain, enable it to retain its pliable quality, and promote its restorative capacity (Begley, 2004; Davidson, Jackson, & Kalin, 2000). In Chapter 3 of the present study, it was posited that mindfulness meditation accesses the socalled love-growth learning response of the mammalian brain, which counteracts the fight-flight stress response of the defensive reptilian brain (Loizzo, 2000, 2006b). It has also been previously established that meditation is a catalyst for learning similar to free association and cognitive restructuring, and it has been linked to neural plasticity (Delmonte, 1990b; Kabat-Zinn, 1992; Loizzo, 2000). Therefore, one may posit that meditation is not only useful in deactivating the stress response during an acute triggering situation, thereby arresting future neural damage; but it may also play a crucial role in rehabilitating and repairing the long-term damage associated with chronic stress and allostatic load. According to Loizzo (2000), Current research indicates that meditation techniques provide teachable methods for consciously changing not just the psychological software of fundamental habit patterns, but even the physical hard wiring of neural networks and wetware of neurotransmitters, hormones and other chemical messengers. Given what neuroscience has been discovering lately about the central organizing role of mind-brain-behavior patterns in health, modern medical science is beginning to understand why the medical systems of the classical world put educational self-healing methods like meditation at the heart of their theory and practice. (p. 147) Summary The present review of the neurological effects of meditation indicates considerable discrepancy among results, a fact most likely related to the lack of standardized designs for assessing meditation effects 116

across studies, the many types of practices assayed, and a lack of technical expertise applied in some of the early studies. Given the wide range of possible meditation methods and resulting states, it seems likely that different practices will produce different psychological effects and also that different psychological types will respond with different psychobiological alterations. EEG meditation studies have produced some consistency, with power increases in theta and alpha bands and overall frequency slowing generally found. Additional findings of increased power coherence and gamma band effects with meditation are starting to emerge. Neuroimaging results are beginning to demonstrate some consistency of localization for meditation practice, with frontal and prefrontal areas shown to be relatively activated. These outcomes appear to index the increased attentional demand of meditative tasks and may be associated with mindfulness-based learning and analysis. However, what is strikingly absent from the literature is the lack of attention paid to neural correlates of ones subjective experience of self, particularly during meditative moments. A greater understanding of the brain functions involved in ones self-experience, would be a prerequisite to future examinations of so-called reproducible experiences of selflessness and boundless compassion. We have yet to isolate or characterize the neurophysiology that makes explicit how meditation induces altered experience of self, in contrast to the Buddhist tradition wherein this is provided in great detail through the use of valid cognition or first- person methodology. Studies of the reported nondual 117

absorptive experience (samadhi) that merges self with the phenomenal world are also needed to establish this state effect. Prospective longitudinal assessments are required to establish trait effects that may reflect subtle neural alterations underlying the shift in the locus of selfexperience and the development of stable unchanging awareness. This review determined that despite appearing to be similar to rest, relaxation, or sleep, in terms of decreased arousal, concentrative training is a consciously cultivated state that prepares the practitioner for contemplation, mindfulness and analysis. While in this state of relaxed alertness, the intuitive function of the brains right hemisphere and investigative function of the left hemisphere are heightened and perhaps brought into synchronization, leading individuals toward deep structural learning, growth, and change. With advances in neuroplasticity research, clinicians in the field are now beginning to see the potential long-term benefits of mindfulness meditation. A decade ago, researchers might have been satisfied conceptualizing mindfulness meditation as an alternative technique for stress reduction. Now, it may be viewed as a learning tool for cognitive retraining, affect tolerance, and reconfiguring the neural wiring of deeply ingrained outlooks, attitudes, and behaviors, as well as enriching and stimulating the natural healing capacity of their nervous system. Equally useful as a preventive measure to lessen acute stress responses and its repercussions, mindfulness meditation has the potential to be a rehabilitative method to repair accumulated damage caused by allostatic

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load. Let us now examine the psychological effects of mindfulness and its efficacy as a clinical intervention for mental illness. CHAPTER 6: MINDFULNESS MEDITATION IN CLINICAL PSYCHOLOGY

Introduction The present chapter focuses on the psychological effects of mindfulness meditation and its potential value as a clinical intervention in psychotherapy. The initial interest in meditation during the late 1950s had scientific researchers identifying its physiological correlates, and later its physical health benefits, in a medical context. In 1960 the now classic Zen Buddhism and Psychoanalysis (Fromm, Suzuki, & De Martino, 1960) provided one of the first cross-cultural, theoretical examinations of these two traditions, heightening academic interest in comparative psychology. This gave rise to a productive dialogue that focused on the integration of ancient Buddhist contemplative practices with Western psychotherapy and psychiatry (Claxton, 1986; Epstein, 1995; Milano, 1998; Pickering, 1997; Segall, 2003; Snaith, 1998; Watson, 1998; Watson, Bachelor, & Claxton, 2000). By the mid-1980s research on the cognitive and psychological correlates of meditation began to take place, with specific interest in its application in a psychotherapeutic context. Early reports of the utility and effectiveness of meditation in clinical contexts were primarily single-case studies. These reports examined the use of meditation for a broad range of 119

clinical issues, yet these findings were preliminary and in need of further substantive research and clinical trials. Mindfulness meditation was shown to reduce: haparanoia (Boornstein, 1983), neurosis (Epstein, 1990a), obesity (Weldon & Aron, 1977), stuttering (McIntyre, Silverman, & Trotter, 1974), claustrophobia (Boudreau, 1972), anxiety (Shapiro, 1976), insomnia (Miskiman, 1977a, 1977b), hypertension (Benson, Rosner, & Marzetta, 1973; Simon, Oparil, & Kimball, 1977), asthma (Wilson, Honsberger, & Chiu, 1975), drug abuse (Benson & Wallace, 1972; Delmonte, 1985; Hayes et al. 2002), alcohol abuse (Shafii, Lavely, & Jaffe, 1975), and various other behavior disorders (Bloomfield, 1977; Glueck & Strobel, 1975; Hayes, Wilson, Gifford, Follette, & Strosahl, 1996; Kelly, 1996; Kutz, Borysenko, & Benson, 1985; Lukoff, Turner, & Lu, 1993; Rubin, 1985, 1991, 1996). With the emergence of meditation in clinical context for the treatment of a wide range of mental health issues, questions were raised regarding its compatibility with Western approaches and methodologies. Does mindfulness meditation lead to improvement or difficulties in psychological adjustment? How does one compare Indian meditation practices and Western therapies, such as free association? Are there dangers in introducing introspective, self-regulatory strategies to patients with limited ego-strength or advanced mental illness? Does meditation offer access to dimensions of the human experience that are largely untouched by Western therapy? Is there a place for a spiritual practice in a therapeutic context?

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In an attempt to address these questions, the present chapter examines and compares the metatheory of Buddhist and clinical psychology. The chapter then reviews articles that compare the techniques of mindfulness meditation and free association. It also discusses the possible complications that might arise when using meditation in a therapeutic context. The chapter concludes by reviewing outcome data from studies involving mindfulness-based psychotherapies, and assessing the clinical value and efficacy of these novel approaches.

Buddhism and Clinical Psychology According to cross-cultural, cross-disciplinary perspectives of some researchers (De Silva, 2000; Epstein, 1995; Goleman, 1981; Loizzo, 1997, 2000, 2006b; Snaith, 1998; Thurman, 2004), Freud located the source of psychopathology in unrestrained unconscious impulses. He viewed the neurotic individual as conditionally reactive to sexual desire (eros) and death aggressive (thanatos) instincts, and in need of bringing these forces into conscious regulation. He postulated that the development of conscious awareness and mature defenses would enable individuals to control their impulses and negate dysfunctional behaviors, thereby civilizing them. In Freuds final estimation, however, the necessary exchange of impulse indulgence for social acceptance was a painful process that resigned individuals to the inevitability of ordinary human misery (Freud, 1961). As Thurman (2004) suggests,

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Western psychology developed during an era of industrialization. Freud and Jung lived in the wealthier societies of central Europe. Members of the middle class finally had a little time and money to explore their general state of being. When their interiors were maladjusted or abused or neglected, they could find someone to work with them. . . . But their [psychologists] main purpose was only to re-adapt these misfits back into the machinery of industrialized society so that their patients could work, function an be normal again. As Freud himself said, his therapy was designed to help people get rid of neurotic suffering so they could get back to ordinary suffering. There was never any mention of complete freedom from suffering as a definition of health, or even a livable option. (p. 38) According to De Silva (2000), roughly 2,500 years before Freud, the Buddha also located the source of human suffering in unconscious impulses. He similarly determined that unrestrained desire and aggression impelled individuals toward repeatedly experiencing anguish and disappointment (dukkha). Some Buddhist-oriented clinicians (Epstein, 1995; Loizzo, 1997) have argued that Freud did not take his analysis of human drives deep enough. For beyond the two secondary impulses lay a primary drive, previously described as the self-reification habit, which operates out of fundamental misknowledge (avidya) (Loizzo, 2000). Individuals are propelled to grasp and avoid, to engulf or destroy, based on their own narcissistic preoccupations, and the erroneous beliefs in their own separate, autonomous, and permanent condition (Loizzo, 1995). According to Goleman (1976), in meditation a set of healthy mental properties reciprocally inhibits an unhealthy set. In light of Abhidharma and empirical findings, applications of meditation are suggested for inducing an optimal mode of responsiveness to environmental demands, and as a complimentary adjunct to psychotherapy. (p. 41)

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Freud discovered that the untrained mind is beyond our control, largely maladaptive, confined by habitual processes, dominated by sexual and aggressive impulse, and operates unconsciously from a position of a false view of reality. The key to the Buddhist retraining of mind is to replace these mental factors with those more conducive to wellness and clarity. Goleman (1976) explains: Just as in systematic desensitization where tension is supplanted by its physiologic opposite relaxation, healthy mental states are antagonistic to unhealthy ones, inhibiting them. In the dynamic of this system, the presence of a given factor disallows the arising of a specific unhealthy factor. The major healthy factor of insight or understanding clear perception of the object as it is suppresses the fundamental unhealthy factor of delusion. [Mindfulness sustains insight], and where there is insight delusion cannot be. (p. 42) According to Western Buddhist proponents (Epstein, 1995; Loizzo, 1997; Thurman, 1998, 2004), because Freud did not locate and address the original impulse of self-involvement, his therapeutic system falls short of providing lasting happiness and relief. As we have seen in the Third Noble Truth, complete liberation (nirvana) from impulsive habit and fundamental ignorance is not only possible, it is every sentient beings potential (tatagathagarbha) and lifes purpose to actualize. The fact that Buddhism and clinical psychology address different levels of negative impulse and have differing methodologies has caused great confusion in the literature regarding their compatibility. Generally speaking, the literature contains two fundamentally opposing views. The sequential view, posited by early researchers, (Bacher, 1981; Engler, 1984; Goleman, 1976; Russell, 1986) maintained that meditation and clinical psychology differed greatly with respect to how 123

they affected the ego. These researchers insisted that psychotherapy and meditation techniques could only be used sequentially, according to an expanded personality development model conceived in transpersonal theory (Walsh & D. H. Shapiro, 1983; Walsh & Vaughan, 1993; Wilber, 1977, 1980a, 1995, 1996). In contrast, the simultaneous view, posited by more recent researchers (Epstein, 1986, 1995; Hirst, 2003; Loizzo, 2000) found Buddhist meditation to be a coherent therapeutic system capable of addressing similar issues as do traditional, cognitive, and dynamic therapies. As such, mindfulness could be prescribed simultaneously with, or independent of, conventional approaches as a means to facilitate psychological adjustment and relief from suffering. Examples of conflicting reports include Deikman (1982), who saw meditative and psychotherapeutic strategies as being focused on different aspects of the individualmeditation analyzing consciousness itself, and psychotherapy analyzing the contents of consciousness. According to the author, Buddhist approaches attempted to eliminate craving altogether by exposing the futility of the attempt to satisfy them; while Western therapy focused on the fulfillment of personal desires, the gratification of the object self (p. 81). In Deikmans (1982) view, meditation was an effective adjunct to the process of therapy rather than as a replacement. Vassallo (1984) explained that by targeting clinging and ignorance, Buddhist meditative practices helped to eliminate the individualistic preoccupation that was at the root of suffering. Western strategies aimed only at coping with the manifestations and symptoms of suffering. Bradwejn, Dowdall, and Iny (1985) strongly agreed that the goal of meditation, the realization 124

of the illusionary nature of the self, was irreconcilable with the goal of therapy, which was the development of a cohesive ego. Mindfulness Meditation Compared to Psychotherapy Kutz et al. (1985) conducted a thorough comparative analysis of mindfulness and the psychotherapeutic technique of free association, both of which involved witnessing mental activity while maintaining an uncritical, nonjudgmental position. They found that mindfulness and free association differed in the way in which mental material was handled, in that free association attempted to interpret the meaning while mindfulness continuously strived to observe the flow of consciousness. In this way way, they concluded that free association enabled individuals to attain a healthy perspective by allowing them to confront unconscious dynamics (repressed negative experiences and defense mechanisms) that arrested psychic development. Conversely, mindfulness led to health when adherents examined perceptual-cognitive habit patterns that reinforced negative affect. According to Kutz et al. (1985), the repeated experience of recognizing the patterns of ones mental process has therapeutic value of its own. The continuous activity of categorizing and decategorizing of mental events gradually provides insight and understanding into how mental schemes and programs are created. Therapies break the hold of past conditioning on present behavior. Meditation tries to alter the process of conditioning per se. (p. 5) Another way researchers compared Buddhist meditation and free association was by defining these disciplines as either covering or uncovering (Russell, 1986). In the covering [techniques], unconscious material that produces problems by threatening to emerge is suppressed. 125

These methods are often used in dealing with crisis, short-term therapy, and patients who are incapable of handling their unconscious emotions (p. 116). Uncovering was defined as a technique used to enable patients to face psychological material and the defense mechanisms that kept them bound in the unconscious. Free association was the classic example of this technique, exposing repressed material and then helping patients integrate this material into a realistic self-image. According to Russell (1986), in the two types of Buddhist meditation, concentration styles were seen as covering techniques because the meditator nonjudgmentally dismissed all mental content except for the chosen subject. Mindfulness was seen as having two aspects: 1) an uncovering technique, in which an open focus allowed for the emergence of repressed material into conscious awareness; and 2) a covering technique because no analysis, working through, or integration of, the subject matter occurred. Instead, practitioners remained present and mindfully aware without actively participating in the stream of consciousness. Engler (1984) concurred with these definitions, which were also identified by Goleman (1976) who explained that the various psychotherapies were directed towards the content of consciousness, while meditation was directed at consciousness itself. Hirst (2003) reported that the practice of mindfulness had many features in common with free association. These included focusing on the contents of consciousness without prior censorship, judgment, or interpretation; accessing instinctual wishes and unconscious impulses; and allowing the forces of repression and suppression to relax. Delmonte 126

(1990a, 1990b) also observed that mindfulness meditation was comparable to free association; since both increased insight and enabled individuals to integrate the perceptual, cognitive, and behavioral aspects of their personalites. Both mindfulness meditation and free association thus opposed repression and promoted health.

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Theoretical Models Combining Techniques The assumption that Buddhist meditation does not encourage analysis of unconscious material brings into question its relevance in psychotherapy. Russell (1986) conducted an extensive review of Buddhist literature and found no significant recognition of unconscious dynamics, as described in the West. It appeared to him that mindfulness meditation and Western psychotherapy possessed completely distinct models of development and mental wellness, and thus prescribed radically different technologies. As Engler (1984) pointed out Buddhist psychology never elaborated a developmental psychology in the Western sense. It has no theory of child development. Nor does it have a developmental view of psychopathology. That is, it does not explicitly place different levels of mental disorder along a developmental continuum according to etiology. What Buddhist psychology and practice appear to do instead is presupposes a more or less normal course of development and an intact or normal ego. For its practice, it assumes a level of personality organization where object relations development, especially a cohesive and integrated sense of self, is already complete. (p. 39) This analysis explicitly defined the difference in how the ego was perceived and defined by Buddhist psychology as compared to how it was seen in Western psychology. Generally, the latter attempts to rehabilitate a defective, nonfunctioning personality, or to correct abnormal or preformed ego constructs. Buddhist psychology aims at optimizing personality by deconstructing the normal, established ego. Engler (1984) underscored this distinction: The therapeutic issue in the clinical treatment of the severe disorders [infantile autism, symbiotic and functional psychosis and borderline conditions] is how to regrow a basic sense of self, or how to differentiate and integrate a stable, consistent and enduring 128

self-representation. The therapeutic issue in Buddhist practice is how to see through the illusion or construct of the self (attaditthi), how to dis-identify from those essential identifications on which experience of our personality is founded. (pp. 30-31) Engler (1984), Russell (1986), and Goleman (1976) reflected the general consensus that each method maintained its own distinct benefits and limitations. According to these researchers, Western psychotherapy was most effective at early developmental stages in the formation of a healthy and stable ego; but had neither the conceptual framework nor the technology to go beyond this point. These authors pointed out that Freud assumed that the objective of psychoanalysis was to bring individuals to a state where they could cope with human suffering. Interestingly, in the Buddhist fourfold medical model the realization of dukkha, or normal human suffering, is seen as the starting place, with the therapeutic path proceeding from there. Buddhism considers normality (the misperception of a rigid and fixed personality) to be a form of pathology and provides a framework and specific technology to expand limited ego defining boundaries. According to Engler (1984), who focused on the limitations of the Western approach, The very attempt to constellate a self and objects that will have some consistency and continuity in time, space and across states of consciousness emerges as the therapeutic problem. The two great achievements in the all-important line of object relations development identity and constancy still represent a point of fixation or arrest. . . . [From the Buddhist] perspective what we take as normality is a state of arrested development. Moreover it can be viewed as a pathological condition insofar as it is based on faulty reality testing, inadequate neutralization of the drives, lack of impulse control, and incomplete integration of the self in relation to the object world. (p. 50)

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The general consensus among researchers is that the divergent strengths and limitations in each system do not make them incompatible or mutually exclusive, as Goleman (1976) explains: Consciousness is the medium, which carries the message that composes experience. Psychotherapies are concerned with these messages and their meanings; meditation instead directs itself to the nature of the medium, consciousness. These two approaches are by no means mutually exclusive, but rather complementary. A therapy of the future may integrate techniques from both approaches, possibly producing a change in the whole person more thoroughgoing and more potent than either alone. (p. 53) Most articles noting the distinctions found that there was some compatibility based upon the concept that each addressed essential aspects of treatment that the other did not. In so doing, a new cartography of personality development that incorporated insights of both Western and Buddhist psychology was proposed by several transpersonal theorists (Engler, 1984; Walsh & D. H. Shapiro, 1983; Walsh & Vaughan, 1993; Wilber, 1977, 1995, 1996). These authors demarcated the transition from preegoic stages to egoic stages to transegoic stages also described as prepersonal to personal to transpersonal (Wilber, 1977). The Sequential Model Bacher (1981), seeing that mindfulness meditation and Western psychology aimed at different types of ego-development, recommended a sequential approach in which psychotherapy preceded meditation, a process which he defined as more beneficial than a blended approach. According to this view, it was necessary to respect ones developmental tasks as defined by existential-humanistic therapy. Self-identification, emotional expression, ego development, and increase in self-esteem were all necessary before individuals could productively undertake the 130

demands of meditation, especially given the fact that the goal of meditation was the disassociation from personal emotions and egoic concerns. Meditation taught the skills of attention and equanimity, a state of inner harmony and balance, and a complete transcendence of the personal concerns that are the focus of psychotherapy. According to Bacher, keeping a clear distinction between them maintained the full integrity and power of each to accomplish its stated aims. He maintained that, although meditation and Western psychology both performed corollary functions in regard to the enhancement of well-being, the intensification of present awareness, and lifting of repression, there were major theoretical differences that made their separation advisable. Russell (1986) pointed out in his review of the literature that there were many indications that a person needed to be fairly well integrated psychologically in order to meditate effectively. Studies supporting the sequential view posited that psychotherapy had to precede meditation because it did not resolve emotional conflict, psychopathology, or advanced mental illness. Furthermore, a sufficient level of personality development and ego-strength, fulfilled only by the methods of conventional psychology, was a prerequisite for subsequent meditative effectiveness (Jamnien & Ohayv, 1980; Kornfield, Ram Dass, & Miyuki, 1983; Welwood, 1983). Englers (1984) famous statement characterized the consensus understanding prevalent in the 1980s and early 1990s: You have to be somebody before you can be nobody. The issue in personal development . . . is not self or no-self, but self and [emphasis added] no-self. Both a sense of self and insight into the ultimate illusionariness of its apparent continuity and 131

substantiality are necessary achievements. Sanity and complete psychological well-being include both, but in a phase-appropriate developmental sequence at different stages of object relations development. (p. 52) Thurman (2004) opposed this view, but kept quiet until enough support could build to challenge its basic presupposition. At a conference in the early eighties hosted by prominent psychologists Thurman (2004) recounted the following: Western psychology helps somebody who feels they are nobody become somebody, and Buddhist psychology helps someone who feels they are somebody become nobody. When I first heard this, I was at an Inner Science conference with the Dalai Lama. Everybody laughed, applauded, and thought it was a great insight. The Dalai Lama just looked at me and kind of winked and was too polite to say anything. I started to jump up to make a comment, but he stopped me. He told me to be quite and let them ponder it for a few years until they realized the flaw in their thinking. Because of course that idea is not even remotely correct. The purpose of realizing your selflessness is not to feel like you are nobody. . . . [I]t means that you become the type of somebody who is a viable, useful somebody, not a ridged, fixated, Im-the-center-of-the-universe, isolated-from-others somebody. You become the type of somebody who is over the idea of a conceptually fixated and self-centered self, a pseudo-self that would actually be absolutely weak, because of being unrelated to the reality of your constantly changing nature. You become the type of somebody who is content never to be quite that sure of who you are always free to be someone new, somebody more. (pp. 5557) The Simultaneous Model In agreement with Thurman (2004) there are other researchers and clinicians in the field who challenged the linear sequential developmental model and instead proposed a simultaneous model (Epstein, 1986; Loizzo, 2000; Loy, 1992; Segall, 2003). In their view, the simultaneous model was based upon a more thorough understanding of the traditional Buddhist 132

teachings of mindfulness meditation, starting with basic bare attention and progressing to the advanced stages of analytic insight. These authors defined analytic insight meditation as a complete therapeutic practice in and of itself, endowed with the same potential for healing as its Western counterpart, psychotherapy. As Segall pointed out, while relatively few authors upheld this view, the research on the simultaneous model was newer, represented a more thorough understanding of the Buddhist tradition, and showed greater cross-cultural sensitivity and respect (Segall, 2003). According to Epstein (1986), Attempts by theorists of transpersonal psychology to explain the place of meditation within the overall framework encompassing western notions of the development of the self often see meditation as a therapeutic intervention most appropriate for those possessing a fully developed sense of self. This approach has been useful in distinguishing transpersonal levels of development from early, preoedipal levels, but appears to have sidestepped the issue of how Buddhist meditation practice, for example, could be seen as therapeutic for psychological issues that have their origin in the infantile experience. . . . It has been noted that some of those attracted to meditation have demonstrated narcissistic pathology, but the role of meditation in transforming narcissistic pathology has not yet been explored. (p. 143) While advocating for the simultaneous model, Loizzo (2000) went a step further by endorsing the independent use of Buddhist practice for a full range of developmental issues and psychopathology. According to his research, the three higher trainings (adhisiksya) need no complement, and have proven efficacy spanning the course of the millennia. Loizzo (2000) rejected previous assertions by Russell (1986) and Engler (1984) that defined mindfulness practice as a covering technique. According to Loizzo (2006b), these early researchers mistakenly thought that mindfulness was not concerned with integration or working through; 133

and, therefore was irrelevant as a prepersonal psychotherapeutic intervention. Loizzo (2000) explains that the final discipline of mindfulness is traditionally defined as analytic insight meditation (vipassana), in which discursive intellect is used before, during, and after meditation sessions as part of a threefold education (trishiksya) aimed at long-term therapeutic change (p. 151). Older description of mindfulness failed to appreciate the potential use and effects at its more advance stages of insight. Loizzo (2000) continues, Like free association, [advanced] mindfulness may be best understood as a cultivated state in which the normal progression from waking to sleep onset is stopped and exploited for deautomatizing, insight and long-term change rather than as a fourth state of consciousness. (p. 159) Phenomenologically, concentration meditation subdues the usual state of hyper-arousal, while mindfulness keeps the attention receptive towards any object of consciousness. When a specific subject is chosen for analysis, skill in concentration retains it indefinitely under observation, while skill in mindfulness allows for discursive probing without emotional reactivity. Mindfulness Meditation and Ego Development Loizzos (2000) topography of techniques placed Buddhist and Western psychological schools next to each other rather than at two distinct ends of a developmental spectrum. In attesting to its integrative nature, Loizzo pointed out that in the Indo-Tibetan synthesis (ekayana), all three aspects of Buddhist developmental psychology were practiced simultaneously, comparable to a family born of one mother (self-analytic 134

insight) and three fathers (renunciation, empathic, and impassioned techniques) (p. 193). Refuting Wilbers (1977, 1980, 1984) transpersonal vision and linear spectrum models, in which Asian practices such as Buddhist meditation did not cure prepersonal neurosis, Loizzo (1997, 2000) called for the acknowledgment of the fact that Buddhist psychology offered a complete therapeutic system. According to Loizzo (2000) classical analytic psychology and Buddhism were both (a) based on a coherent philosophy of mind; (b) biologically grounded; and, (c) provided therapeutic techniques, based on the union of subjective transformation and interpersonal relationships. Consistent with Loizzos position, Mark Epstein a Buddhistoriented psychoanalyst and author, finds Buddhism to be a coherent psychological system capable of addressing prepersonal issues among others. Epstein (1986, 1995, 1998, 2001, 2005) has identified several ways in which Buddhist meditation addressed the early developmental deficits typically associated with the therapeutic work of classical Ego and Self psychology. Specifically, Epstein (1986) acknowledged the usefulness of transpersonal developmental models, such as the spectrum of consciousness (Wilber, 1977), the developmental spectrum of psychopathology (Wilber, 1984a, 1984b), and the pre/trans fallacy (Wilber, 1980b) but viewed them as oversimplifications. In his estimation, the theoretical boundaries between prepersonal, personal, and transpersonal stages of development were not clearly defined in clinical practice.

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For example, these transpersonal models viewed narcissism as an ethno-specific phenomenon endemic to our culture and generalized that Western psychology was concerned only with lower level or prepersonal development; while Eastern psychology was concerned only with upper level or transpersonal development. On the contrary, Epstein viewed narcissism as a disease of all humanity; and contended that Buddhist treatments could be beneficial at any level of development. To emphasize his viewpoint, Epstein (1986) pointed to the fact that ancient Indian culture possessed an underlying trust in the meditationbased spiritual disciplines to resolve prepersonal conflicts and narcissistic issues. He also found accounts in traditional Buddhist literature that people of all psychological dispositions and stages of ego development attained enlightenment while studying with the Buddha. In agreement with Epstein, Nyanaponika (2001) also cited a case of a disturbed mass murderer named Moggallana who would today probably meet the criteria for having an antisocial personality disorder. According to the author, Moggallana eventually mastered mindfulness meditation, became adept at psychic abilities, achieved liberation, and was chosen by the Buddha to be among his chief disciples. Epstein (1986) concluded that such a cure was possible because the path of insight led to the final extinction of defilements (kleshas), including primary narcissistic disturbances. Goleman (1977) also reported that until the attainment of sainthood (arhant), the seventh stage on the path of insight, individuals still struggled with neurotic issues, such as lust, greed, hostility, selfpreoccupation, and self-annihilation. Epstein (1986) stated that there was 136

a narcissistic residue left from preoedipal stages of development that persisted throughout the entire life cycle, but that mindfulness meditation was suitable in controlling this residue: Just as this narcissistic residue reverberates throughout the life cycle, affecting goals, aspirations and intimate relationships, so it can be seen to reverberate throughout the meditative path, where psychic structures derived from this infantile experience must be, at various times, gratified, confronted, and abandoned. (p. 145) An opposing view was presented by Dubbss (1987) study, which did not support mindfulness as a means to cope with unresolved psychological issues. He used interviews and questionnaire assessments of 30 long-term meditators; in this way, he identified unresolved anger and narcissistic rage as key elements in their resistance to progress in meditation. He suggested that psychological and spiritual growth were linked, but leaned toward a more sequentially developmental model. Using the same argument that narcissistic tendencies persisted beyond developmental boundaries, Epstein (1986) contended that meditative disciplines had the potential to be useful in their psychotherapeutic treatment and did not have to be relegated only to advanced issues in personal development. The Ego Ideal and the Ideal Ego According to Hanly (1984), advanced mindfulness meditation addressed problems that stemmed from an imbalance between the individuals ego ideal and the ideal ego. He pointed out that the ego ideal identified the source of abstract ideas that the ego had about itself (perfect, complete, immortal), derived from a long series of denials. He defined the 137

ideal ego as embodying the aspiration to transform ones being, arising from the dissolution of omnipotence created when the mother-child duality was first recognized. Epstein (1986) explained that the function of the ideal ego is to assure the self of its own inherent perfection [while] the ego ideal is associated with a yearning to become something that at its roots is an internalized image of a lost state of perfection (p. 147). Epstein (1986) proposed that the two types of Buddhist meditative disciplines could be used to balance tensions between these two egoic forces. The concentration type, characterized by pleasurable feelings of rapture, bliss, expansiveness, and wholeness, could be used to appease the ego ideal. The mindfulness type could provide a clear perception of successive mindful moments; and ultimately reveal their impermanent, insubstantial, and unsatisfying nature. This last process, however, could initially result in feelings of anxiety and panic that undermined the power of the ideal ego by forcing the individual to integrate harsh and dissatisfying dimensions of reality. As Epstein (1986) pointed out, because advanced Buddhist meditation (vipassana) incorporated both types of practice simultaneously, it had the capacity to strengthen the ego ideal when a sense of cohesion was necessary; and, at the same time, diminish the ideal ego which fueled a sense of self-importance: the Buddhist texts are very clear about the need for precise balancing of concentration and insight practices, and, while they do not use contemporary language of narcissism, it is clear that they are counseling an approach that balances an exalted, equilibrated, boundless state with one that stresses knowledge of the insubstantiality of the self. . . . For meditation may ultimately be conceptualized as a vehicle for freeing an individual from his own narcissism, a liberation that is not complete until enlightenment. Until that point, the individual is subject to the pressures of his 138

own narcissistic impulses, and the experience of meditation may be recruited to satisfy those impulses, at the same time those experiences force a confrontation with narcissistic attachments. (p. 155)

Reparenting the Ego Epstein (1995, 1998) proposed another way that mindfulness meditation could be psychoanalytically viewed and clinically applied in the service of ego-development, namely that of reparenting oneself in order to attain greater ego stability and affect tolerance. Personality disorders in the borderline-narcissistic spectrum of pathology typically indicate primitive arrests in ego development associated with, among other things, empathic failures and lack of affect regulation in the motherinfant dyad (Mahler, 1975; Masterson, 1981). As a result, in adulthood negative emotions are too threatening and overwhelming for such a patient to endure. Epstein (1995) postulated that mindfulness meditation could enable individuals to learn how to self-regulate affect, in much the same way that a mother both attends and attunes to a childs distressing emotions while maintaining a necessary but nurturing detachment: It is the openness of a mother who can, as D. W. Winnicott pointed out in his famous paper The Capacity to Be Alone, allow a child to play uninterruptedly in her presence. This type of openness, which is not interfering, is a quality that [mindfulness] meditation reliably induces (p. 115). Mindfulness strengthens skills in the observing ego to attend to afflictive affect without overidentification; while at the same time, it fosters an attitude of loving kindness (Pali, metta; Skr, maitri) and acceptance, all of which are needed to create optimal frustration, delay gratification and build distress-tolerance. According to Epstein (2001), the 139

continued practice of mindfulness meditation over time has the capacity to provide the corrective emotional experience that is required for the ego to mature and progress. Regarding the mechanisms, he (1995) states, By separating our reactive self from the core experience, the practice of bare attention eventually returns the meditator to a state of unconditional openness that bears an important resemblance to the feelings engendered by an optimally attentive parent. It does this by relentlessly uncovering the reactive self and returning the meditator, again and again, to the raw material of experience. According to Winnicott, only in this state of not having to react can the self begin to be. (p. 117) In his discussion of the psychodynamics of meditation, Epstein (1995) clarifies his view on what the two respective traditions of psychology and Buddhism have to offer, and contradicts the conventional notion that they address different aspects of ego-development. Much of what happens through meditation is therapeutic, in that it promotes the usual therapeutic goals of integration, humility, stability, and self-awareness. Yet there is something in the scope of Buddhist meditation that reaches beyond therapy, toward a farther horizon of self-understanding that is not ordinarily accessible through psychotherapy alone. (p. 130). In this way, it can be seen that mindfulness meditation has the potential to resolve issues of ego-cohesion at prepersonal and personal levels of organization as well as to facilitate transcendence of the limited selfidentification typical at higher levels of neurotic functioning. Kornfield (1983) also indicated that mindfulness meditation addressed prepersonal and/or personal conflicts along the developmental spectrum. He contended that, while Western therapy emphasized analysis, investigation, and the adjustment of personality, it neglected the development of concentration, tranquility, and equanimity. In his view, 140

concentrative absorption (samadhi) was able to penetrate the surface of the mind, enabling individuals to use this awareness to cut neurotic issues (p. 37). Kornfield maintained that meditation was not only a means of seeking comfort and stability, but of working with inner turmoil in such a way that profound transformation occurred, which resulted in the death of the self. Later, however, Kornfield (1989) admitted that meditation was not a cure-all. He came to believe that in many areas, such as grief, childhood wounds, communication skills, maturation of relationships, sexuality and intimacy, career and work issues, and fears and phobias, Western therapies were better equipped, quicker, and more successful than meditation alone. Nevertheless, Kornfield suggested using these forms of therapy in tandem with mindfulness meditation. Loizzo and other researchers (Epstein, 1995, 2005; Thurman, 1998; B.A. Wallace, 2001) maintained that Buddhist meditative psychology was a complete and effective psychotherapeutic system in and of itself. Contrary to Wilber (1980) and other transpersonal scholars, Buddhism does not necessarily require Western developmental models to complete or fill in its theoretical and practical gaps. Furthermore, Buddhist therapy does not require integration with conventional therapy in order to benefit patients with prepersonal or personal mental disorders. The need for Western clinicians and researchers to identify mindfulness meditation as something distinct from the objectives and goals of psychotherapy, or to abstract Buddhist techniques and integrate them into their own conventional therapeutic systems, may reflect either Eurocentric

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insecurity, or perhaps their lack of appropriate exposure to the metapsychology of the meditative traditions (Thurman, 1984).

Contraindications of Mindfulness Meditation Complications and Negative Effects While there are conflicting reports as to how mindfulness meditation contributes to health, evidence exists supporting its possible side effects. Epstein and Lieff (1981) provided the most comprehensive review on psychiatric complications due to its practice. In most of these cases, the people who experienced negative effects were beginning students, although late complications in advanced students were reported as well. According to the authors, Depolarization and derealization experiences are reported by many practitioners to be ego-syntonic side effects of their meditations. In some cases, the feelings may be of such intensity as to necessitate psychiatric consultation and may, by virtue of their foreignness, precipitate panic attacks. Anxiety, tension, agitation, and restlessness may all be paradoxically increased through the practice of Transcendental Meditation. Exacerbations of depressive affect to the point of attempted suicide may also follow TM experience. Perceptions of extreme euphoria accompanied by powerfully compelling fantasies and MMPI [Minnesota Multiphasic Personality Inventory] evidence of excessive pressure from unconscious material followed by unbearable dysphoria is described in a previously well 38-year old woman following beginning practice of meditation. Grandiose fantasies evolving into religious delusions with messianic content are described in a 24-year old male following prolonged meditation in an isolated environment. Three psychotic episodes, characterized by agitation, paranoia and suicide attempts, are described in individuals with a history of schizophrenia participating in intensive meditation retreats associated with fasting and sleep deprivation. Two psychotic episodes, in young psychiatric patients with previous LSD experiences, are described after TM training. (p. 138) 142

As Epstein and Lieff (1981) pointed out, it was evident that meditation could cause profoundly negative experiences in beginning students. The authors offered two psychoanalytic explanations for these negative symptoms. The first was that meditation could cause a regression to primary narcissism; and the second, that individuals lacking sufficient ego strength were unable to cope with the re-emergence of repressed material. While Epstein (1986) maintained that meditation had the capacity to be effective throughout all phases of personality development, he agreed with Engler (1984) that a precondition for this effectiveness was having a requisite high level of personality organization. Bradwejn et al. (1985) also cautioned that before combining therapy and meditation, the developmental levels of the patient must be carefully considered. Nevertheless, given the recent physiological understanding of the relaxation response, it is strange to see such physical side effects as restlessness and anxiety. More alarming, indeed, are the several cases that reveal mental instability of some sort in the form of paranoia, anxiety, or delusion. Regression to Primary Narcissism The regression to primary narcissism was first perceived by Freud (1930) in his critique of mystical experience. In this paper, he identified states of ecstatic union, or oceanic feelings reported by meditators, as a regression to infantile stages of development. According to Epstein and Lieff (1981) Freud associates this oceanic experience with the most primitive stage in the development of ego, that of undifferentiation between self and mother, or primary narcissism. In this view, meditation is 143

seen as a libidinal, narcissistic turning of the urge for knowing inward, a sort of artificial schizophrenia with complete withdrawal of libidinal interest in the outside world. The spiritual urge, postulated Freud, seeks a restoration of limitless narcissism, an evocation of the outgrown mother-child bond employed as a kind of transitional object designed to protect against the fears of separateness. (p. 139) For Freud (1930), the inability to accept solitary existence marked an arrest in egoic development that could cause psychological complications, such as maladaptive behavior and dependency. In the Buddhist traditions, blissful states are seen as potential hindrances, and should be tempered with the same concentration that induces them. It can be seen that the above-described experiences of union and reunion are capable of becoming become protective devices that individuals use as shelters from the pain of being autonomous. And given the current phenomenological understanding of the potential euphoric effects of concentrative meditation, beginning students could also misinterpret such experiences as an awakening, or union with God; or unconsciously, as a reunion with their mother. This misinterpretation could lead to delusion, or paranoia, and to the development of a neurotic longing for this sense of security. The Emergence of Repressed Material Epstein and Lieff (1981) pointed out the inability of some practitioners of mindfulness meditation to cope with the emergence of repressed material. Other researchers (Engler 1984; J. Miller, 1993; Russell, 1986) established the fact that, though the psychotherapeutic benefit of meditation was its ability to uncover unconscious material, at the same time, it did not offer individuals the means to deal with the material that 144

was raised. This left open the possibility that numerous psychological complications could arise, such as fear, paranoia, anxiety, and even schizophrenia. The researchers viewed these symptoms as especially problematic among individuals whose ego was undeveloped, and who were unable to cope with the emerging content. As Epstein and Lieff (1981) noted, the meditation experience offers the opportunity to egosyntonically re-experience and reexamine unresolved conflicts and drives embodied in material which unfolds. . . . [M]editation can be seen as an arena in which to uncover primitive material, with side effects resulting when ego strength is not sufficient to withstand the force of such material. (p. 139) These above explanations made clear that the personality development and ego-stability of the beginning student were crucial in the prevention of complications. Review of Adverse Effects The early psychological literature contained relatively few studies that reported adverse effects associated with mindfulness meditation (Carrington, 1977; Epstein, 1990b; Lazarus, 1976; Shapiro, 1992; Walsh & Roche, 1979). Epstein and Lieff (1981) reviewed psychological complications corresponding to developmental levels of the meditation experience. J. Miller (1993) and Delmonte (1990a) studied the potential for retrauma as a result of the meditative unveiling of repressed memories. In each of these studies, negative consequences were attributed to the patients being insufficiently prepared for the emotional work involved in meditation. In all other cases cited, caution was suggested rather than the exclusion of the treatment. 145

After reviewing a broad range of mind-body therapies currently in use in medicine and psychiatry, Astin et al. (2003) provided several useful findings with regards to potential adverse effects. The authors noted that, unlike pharmacologic trials, there appeared to be no established tools for assessing adverse events associated with mind-body therapies. Despite this, they gave examples of several controlled studies which reported that patients experienced 17% to 31% increase in anxiety during relaxation meditation, and as high as 53% during mindfulness meditation. This significant and seemingly ironic increase could have been accounted for by the fact that mindfulness encouraged continued attendance to experience, while concentration attempted to bypass or suppress it. In addition the authors compiled a list of several adverse experiences noted during meditation including unfamiliar feelings and sensations, intrusive thoughts, a sense of losing control, floating, muscle cramps and spasms, dizziness, feelings of vulnerability, sensations of heaviness, and myonclonic jerks. However, in a poll involving 116 psychologists using meditation, only 3.8% of their patients needed to terminate as a result of these and other side effects. While transitory negative side effects are relatively infrequent, Astin et al. (2003) concluded that it was only prudent to apply such therapies after careful evaluation of patients and in the context of an appropriate professional relationship (p. 139). Stage Model of Meditative Complications Are there complications for advanced practitioners as well as side effects for those with more integrated personalities? To answer this one 146

needs to view both personality and the expansion of consciousness through meditative practice in a more extended developmental sequence. At each progressive stage in development, new complications can arise while those previous can be subverted. Based on a condensed version of the traditional Buddhist model of the path of insight discussed in Chapter 3, Epstein and Lieff (1981) identified possible psychological complications according to four stages of meditative development. Stage 1. Preliminary Practice In the first stage of mindfulness meditation, beginners observe and confront their mind, perhaps for the first time. In the process of trying to train and control the ever-wandering mind, the practitioner is apt to feel inadequate, frustrated, worthless, overwhelmed, and afraid. Meditators might question who is in control of their mental states as well as the validity of their emotional experiences. In the Epstein and Lieff (1981) study, subjects frequently reported unusual experiences, visual and auditory aberrations, hallucinations, and unusual somatic experiences (p. 142). Subjects with sufficient ego development remained comfortable throughout these experiences, and successfully moved to the next stage of development. But those without the ego-stability necessary to weather the storm of the mind were more likely to experience psychological friction and complication. Epstein and Lieff (1981) stated, On the more primitive end of the continuum of ego development, there are some whose precarious defense mechanisms cannot withstand the onslaught of this

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internal experience. Thus psychotic defense mechanisms of denial, delusional projection, and distortion may manifest (p. 142).

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Stage 2. Access Concentration The second stage marks the practitioners initial experience of genuine concentration on the object of meditation. For the first time, they control what is known in Buddhism as the monkey mind, the result of which is their experiencing the first successful level of the practice. Although concentration is not yet refined, practitioners intentionally place their attention on a single object (for a brief period of time), and nonjudgmentally observe the arising and falling of thoughts. For the novice, this stage marks the introduction of relief, inspiration to continue practice, and increased self-worth. But, along with these new abilities, there often arises a destructive ambition to control the results of meditation. When practitioners try too hard, they can wind up blocking their aims, and experience such problematic effects as anxiety, agitation, and physical pain in the shoulders, neck, and back. Some adherents of the Buddhist tradition diagnose this disorder as Zen sickness, the desire for more control; although, when done correctly, mindfulness meditation attempts to counter such effects Stage 3. Samadhi In Stage 3, meditators are able to access further levels of absorption (jhana) or trance. These stages introduce pleasant subjective experiences, such as feelings of peace, calm, joy, and equanimity; and then progress to more abstract sensations, which correspond to the formless realm. These positive results, however, can become the object of attachment and

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clinging, factors which contribute to further suffering. According to Epstein and Lieff (1981) Higher states of meditation contain numerous experiences involving visions of bright lights, joyous and rapturous feelings of body and mind, tranquility, lucid perceptions, and feelings of love and devotion. . . . These states exert seductive influences which can become quite serious according to meditative traditions [and] attachment to these states marks a major abuse to the meditative process. It is not until the pride is made the object of meditation that the individual can pass beyond this stage. (p. 144)

Stage 4. Insight If the path of mindfulness is developed after concentration has been significantly strengthened, then further psychological experiences can occur. Nonjudgmental observation of the moment-to-moment nature of the mind, which involves noticing the arising and passing of thoughts, allows for the acquisition of wisdom. By directly experiencing the transient, essenceless, and ultimately unsatisfactory nature of all things, meditators awaken in themselves a profound insight into reality. At the same time, this spontaneous illumination can have negative consequences. Individuals who are able to discriminate between very subtle moments of consciousness challenge their previous assumptions and understanding of duality, which can result in an existential predicament. Epstein and Lieff (1981) add that A period characterized by the subjective experience of dissolution is entered where traditionally solid aspects of the personality begin to break up, leaving the meditator no solid ground to stand on. This is traditionally a time of spiritual crises, characterized by a great terror, the Great Doubt, and as the struggle to allow a transformation or decathexis of the self. (p. 144) 150

Clinical Value of Mindfulness Meditation Mindfulness Meditation: Adjunct to Psychotherapy Mindfulness and Short-Term Psychotherapy Deatherage (1976) studied the effectiveness of mindfulness meditation as a primary and secondary technique with a variety of psychiatric patients in short-term therapy. He conceptualized meditation as a self-treatment regimen with various benefits that included introducing patients to their own mental processes and preoccupations, and presenting a method of access and control over these processes, as well as its high efficiency and cost-effectiveness for the therapist. Studies by Carpenter (1977) and D. H. Shapiro and Giber (1978) showed that the efficacy of mindfulness practice arose from its dual function of relaxation and insight. In this way, mindfulness meditation helped practitioners cope with stress reactivity by instilling in them a sense of tranquility (shamatha). This, in turn, led to the establishment of skills in selfobservation, and cognitive reconstruction, and to a more realistic understanding (vipassana) of present experience.

Mindfulness and Long-Term Psychotherapy Kutz et al. (1985), in considering the integration of mindfulness meditation with psychotherapy, hypothesized that the mechanistic differences between the two techniques allow these two forms of selfobservation to complement one another (p. 1). The authors considered several factors that made meditation relevant to psychotherapy, beginning with the perceptual retraining feature that enabled individuals to distinguish between thoughts and emotions. Through this form of 151

detached observation, patients could perceive a mental object and its concomitant emotion as separate, distinct entities; and with this insight, be able to witness how their own thoughts gave rise to afflictive emotions, thus empowering them to minimize the negative psycho-somatic pathway. Practitioners of mindfulness meditation also cultivated a greater use of primary process thinking. As Kutz et al. (1985) explained, in the meditative state, primary process thinking is first experienced as intensified perceptual awareness. Objects and their perceptual representations appear more vivid, and there is greater awareness of their primary qualities, such as form and color. Any object in this state can be seen more for what it is rather than just for the function it represents. . . . Thus objects acquire a quality of firstness. . . . which introduces greater conceptual flexibility, as the meditator can consider objects and events outside their usual conditioned secondary context. (p. 4) This heightened perceptual sensitivity, which is associated with primary process thinking, has a two fold benefit. Primarily, it brings a sense of newness and freshness to the patients everyday experiences; but it is also an aid in therapy, helping patients understand their internal dynamics. In this way, it can be seen that mindfulness cultivates an emotional receptivity instead of reactivity. This loosens unconscious defenses and allows the emergence of repressed material, which can then be examined by the nonlinear, flexible, and nonjudgmental rules of primary process thinking. Kutz et al. (1985) concluded their study by highlighting three significant advantages to the use of mindfulness meditation in psychotherapy: First, they felt that mindfulness acted as a daily and personal form of psychotherapy:

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It is the cognitive stance that makes mindfulness meditation so suitable as an adjunctive psychotherapeutic tool. The meditator can be engaged in a psychobiological form of introspection, outside the psychotherapeutic session. Through meditation, therapy is transformed into a daily schedule, as it was prescribed in its heyday. (p. 6) Second, they maintained that the continued practice of mindfulness served as a preparatory forum for the weekly therapeutic session. The multidimensional, primary processed material displayed during meditation, as well as the capacity of the observing ego to become aware of its own contents, provide abundant raw material that can be expanded on in the weekly psychotherapy meetings (p. 6). Third, the authors stated that psychotherapy and mindfulness were technically compatible and mutually reinforcing: Psychotherapy contains the notion that the understanding of ones pain and the defenses against it can alleviate suffering and promote psychological growth. As such, it shares with the Buddhist tradition the goal of liberation through self-exploration. . . . The inclusion of meditation should be seen within this context. Modern sciences can provide the expanding knowledge and framework of biological and behavioral sciences. Meditation traditions, particularly Buddhism, provide not only the technology of meditation practice but also the spirit behind the philosophy that regards any mental construct, including this model, as a mere explanation and, as such, impermanent and partly illusionary. The addition of meditative techniques to psychotherapy should not challenge psychotherapy nor reduce the function of the therapist. (p. 7)

Mindfulness and Psychoanalysis Rubin (1991) reported on the clinical integration of mindfulness meditation and psychoanalysis involving a case study of long term patient of his who had recently been trained to meditate. After a year with this patient, Rubin found that 153

meditation, the core practice of Buddhism, can enrich psychoanalytic treatment. Buddhist practice can enhance selfobservational capacities and thus heighten self-awareness; facilitate access to unconscious material and enhance empathic attainments; reduce self-recriminative tendencies; facilitate self-demarcation, increase affect tolerance and integration and reduce depressive affect; and foster deautomatization of thought and action. (p. 197) The author concluded that judiciously applied meditation supplemented and complemented psychoanalysis; and he encouraged the continued intermixture of these two forms of personal transformation. In a previous study, Rubin (1985) found that mindfulness enriched psychoanalytic listening by developing in the analyst what Freud called an even-hovering attention. In so doing, the practice then benefited the therapist as well as the client. Lesh (1970) also noted increased empathy in counselors as a result of meditation, a finding that was validated by several other studies (Delmonte, 1990b; Dreifuss, 1990; Dubin, 1991; Sweet & Johnson, 1990). These studies all pointed to the fact that the acumen of the therapist was greatly enhanced by an ability to be perceptually and emotionally present to the client and cognitively free from judgment regarding the issues that arose. According to Rubin (1985), in discussing the benefits of meditative mental restructuring, daily life is often pervaded by mindlessness or inattentiveness and automatically of thought and action. Our typical mode of perception is to an unrecognized extent, selective, distorted and outside voluntary control. We often operate on automatic pilot reacting to a conscious and unconscious blend of fallacious association, anticipatory fantasies, and habitual fears that make us unaware of the actual texture of our experience (p. 606)

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Mindfulness-Based Psychotherapies Mindfulness-Based Cognitive Therapy An initial study by Teasdale, Segal, & Williams (1995) determined how mindfulness complemented conventional cognitive approaches to depression-relapse prevention. Their rationale was based upon the fact that structured cognitive treatments for depression caused some clients to experience a relapse after the period of initial implementation. The authors pointed out the need for the continuation of preventive psychological approaches, which could be administered to recovered patients who were in a euthymic mood. An information-processing analysis of depressive maintenance and relapse was used to define the requirements for effective prevention and to propose mechanisms through which cognitive therapy could achieve a prophylactic effect (Teasdale et al., 1995). The analysis suggested that similar effects could be achieved through the use of techniques of stressreduction based on attentional control that was taught in mindfulness meditation. Teasdale et al. (1995) presented an information-processing analysis of mindfulness and mindlessness, and of their relevance in preventing depressive relapse. This analysis provided the basis for the development of Attentional Control Training (ACT), later changed to Mindfulness-Based Cognitive Therapy (MBCT) that could be used by recovered depressed patients. This training integrated features of cognitive therapy and mindfulness training, and was a new approach to the prevention of relapse.

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Teasdale (1999) further contributed to the research on mindfulness by enumerating the precise mechanisms that distinguished it from cognitive therapy. He made a clear distinction between metacognitive knowledge (knowing that thoughts were not necessarily always accurate) and metacognitive insight (experiencing thoughts as events in the field of awareness, rather than as direct readouts on reality). These findings supported the research of Kabat-Zinn (1982), who found that disidentification was the key feature of mindfulness meditation in symptom reduction. Teasdale (1999) examined this distinction, and its relevance to preventing relapse and recurrence in depression, within the Interacting Cognitive Subsystems theoretical framework. As an alternative to cognitive therapy with its focus on changing the content of depressionrelated thought, his analysis focused on changing the configuration, or mode, within which depression-related thoughts and feelings were processed and experienced. The facilitation of this metacognitive insight mode, in which thoughts are experienced simply as events in the mind, can be a useful clinical strategy. And whereas cognitive models attempt to transform unhealthy thinking patterns by changing or substituting thought-patterns themselves, mindfulness meditation alters the way one relates to these thought-patterns, by viewing them as distinct entities. Depression-relapse studies such as Teasdales (1988) indicated that depressive moods reactivated unhealthy thinking and made cognition patterns difficult to alter, emphasizing the fact that it is was more effective to change ones relationship to cognitive schemas than it was to change ones thoughts. 156

Support for this above hypothesis came from Teasdale et al. (2000) who evaluated MBCT as a method to help recovered recurrently depressed patients disengage from dysphoria-activated, depressogenic thinking. In this study, 145 recovered recurrently depressed patients were randomized to continue with treatment as usual or, in addition, to receive MBCT. Relapse/recurrence to major depression was assessed over a 60week study period. Over the following year, for those (77% of treatment group) with three or more previous episodes of depression, MBCT treatment significantly reduced relapse from 66% (control group) to 37% (treatment group). For patients with only two previous episodes, MBCT did not reduce relapse/ recurrence. This was statistically significant, given the findings of Keller, Lavori, Lewis, and Klerman (1983) whose study concluded that 67% of patients with three or more depressive episodes relapsed, as opposed to only a 22% relapse probability for depression first timers. The authors proposed that MBCT was more effective among patients who had experienced at least three episodes of major depression because it was designed to reduce the patterns of depressive thinking associated with dysphoria, a form of thinking exacerbated by repeated episodes of depression. Keller et al. (1983) cautioned, however, that MBCT, which was intended for use upon recovery from depression, was not likely to be as effective during an acute depressive episode. According to the authors, during an acute depressive episode, the patients difficulties in concentration, and the intensity of negative thinking, interfered with their 157

ability to acquire the attentional control skills central to the program. The authors concluded that MBCT held considerable therapeutic promise, either alone or in combination with other forms of intervention. Teasdale et al. (2000) found that mindfulness was more effective with the higher risk group, for which traditional, nonpharmacological therapy was relatively unsuccessful. According to the authors, MBCT offered a promising, cost-efficient psychological approach to preventing relapse/recurrence in recovered recurrently depressed patients with more than two episodes; precisely the number currently utilized in diagnosing major depressive disorder. Cost benefits were derived as the result of two factors: (a) MBCT could be taught in a group educational format, lowering treatment expenses and conserving the psychologists time; and (b) for clients in individual therapy, skills and insights could be developed more rapidly because much of the therapeutic experience would occur outside the clinical hour. Mason and Hargreaves (2001) balanced the quantitative data with a qualitative study on the use of MBCT for depression. This study explored the participants' accounts of MBCT in the mental-health context. Seven participants were interviewed in two phases. Interview data from 4 participants were obtained in the weeks following MBCT. Grounded theory techniques were used to identify several categories that combined to describe the ways in which mental-health difficulties arose as well as their experiences of MBCT. Three further participants who continued to practice MBCT were interviewed in order to further validate, elucidate, and extend these categories. The study suggested that the preconceptions 158

and expectations of therapy were important influences on later experiences of MBCT. In the above study by Mason and Hargreaves (2001), significant areas of therapeutic change and coping skills were identified, including the development of mindfulness techniques, acceptance of discomfort and being able to live in the moment. The development of these mindfulness skills was seen to hold a key role in enabling patients to grow and heal. Using these skills in everyday life was also seen as important, and several ways in which this could occur were studied, including the use of breathing spaces, also known as mini meditations. The study further emphasized the importance of patients continuing to adhere to the practice in order to strengthen their therapeutic gains. Dialectical Behavior Therapy DBT is a multifaceted treatment approach used with patients diagnosed with borderline personality disorder. Borderline pathology represents an arrest in the development of ego, characterized by deficits in self/other boundaries, affect tolerance, self-efficacy, and reality testing. Patients diagnosed with this disorder are prone to homicidal and suicidal ideation and behavior, and episodically fall into acute crisis. A borderline patients inability to tolerate anger and rejection, the incessant devaluing of the therapist, and lack of capacity for insight make psychotherapy, particularly of a dynamic nature, problematic and often short-lived (Johnson, 1994). DBT refers to the metaphilosophy influenced by Zen Buddhism that acknowledges opposing forces in reality, the synthesis of which leads 159

to a new reality (Linehan, 1994). The central dialectic of this treatment concerns the relationship between change and acceptance. Patients are asked to change those things that are within their control, such as replacing dysfunctional behaviors, attitudes, and outlooks, and to avoid environmental triggers (people, places, and things). Simultaneously, they are encouraged to accept those things that are beyond their control, such as their traumatic history, character deficits, physical limitation, and/or current situation. The primary goals of DBT are distinguishing between what can be changed and what must be accepted, as well as their eventual reconciliation. DBT is long-term and intensive in nature. Patients work with an individual therapist, participate in skill building groups for at least a year, meet regularly with a psychiatrist if medicated, and are monitored using a variety of standard progress oriented measures. In addition, DBT therapists are required to undergo intensive training and meet regularly in case collaboration. As in traditional cognitive-behavioral therapy (CBT), the focus of the treatment is on developing control over the coinfluence of thoughts, emotions, and behaviors. However, DBT differs in that mindfulness meditation is incorporated in order to provide patients with a more expedient self-observational tool that accelerates learning and skills development. Linehan (1993a, 1993b) found that mindfulness practice strengthened three core skills: (a) interpersonal effectiveness, (b) emotion regulation, and (c) distress tolerance. She maintained that meditation provided a structured context for self-observation and self-

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understanding that facilitated treatment between therapy sessions and group activities. The first controlled trial of DBT involved chronically suicidal patients with borderline personality disorder (Linehan, Armstrong, Suarez, Allmon, & Heard, 1991). During the posttreatment follow-up at one year, patients had significantly fewer parasuicidal acts, required fewer hospitalizations, and stayed in treatment longer than the treatment-asusual control group. Other DBT studies demonstrated equally significant improvements with borderline patients actively engaged in substance use (Linehan et al., 1999), binge eating (Telch, Agras, & Linehan, 2001) and bulimia (Safer, Telch, & Agras, 2001). Research indicated that DBT was the most empirically validated and clinically effective treatment for patients with borderline personality disorder (Bohus et al., 2000; Clarkin, Levy, Lenzenweger, & Kernberg, 2004; Lazar, 2005; Linehan, Tutek, Heard, & Armstrong, 1994; Robins & Chapman, 2004). Early meditation researchers (Bacher, 1981; Engler, 1984; Goleman, 1976; Russell, 1986) suggested that meditation was contraindicated for use by patients with serious mental illnesses or limited ego development. This contention conflicted with several recent studies (Bohus et al., 2004; Linehan, 1991; McQuillan et al., 2005) reporting that a borderline population appeared to improve on a variety of subjective and behavioral scales after learning mindfulness skills. The research is as yet unclear whether or not meditation is useful for patients with severe pathology and personality disorder, although there are a few examples of the effective use of mindfulness with more chronically disturbed patients. One study 161

that standouts by Bach and Hayes (2002) showed a 50% reduction in rehospitalization for patients with psychotic symptoms after only four sessions of a mindfulness-based intervention known as ACT. A single-case study (Singh, Wahler, Adkins, & Myers, 2003) of a mildly retarded patient given a simplified mindfulness practice showed that he experienced decreased levels of aggression and increased selfcontrol, sufficient enough to permit him to live in a residential community setting. Linehan (1994) pointed out that lower functioning patients were often unable to practice mindfulness as intensively as was clinically recommended (Kabat-Zinn, 1990; Segal et al., 2002); although with adaptations to frequency and duration, it became possible for them to benefit. DBT research has lent support to the concept that mindfulness could be judiciously applied to a wide spectrum of mental illnesses and need not be relegated to neurotic or higher functioning individuals (Loizzo, 2000). The perspective of traditional Tibetan and Indian Buddhist psychiatry and medicine (Clifford, 1984; Loizzo, 2006b) is that meditation is contraindicated when a patient does not possess the capacity for selfreflection and learning, either due to biological or psychological deficit. In these cases, Buddhism recommends natural remedies to alter biochemistry, based on very elaborate systems of Indo-Tibetan and Aurvedic medicine. There are conflicting reports between Western and Buddhist sources as to the prerequisites of meditative learning and those who should be excluded from using the technique.

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Mechanisms of Clinical Effects in Mindfulness With the advent of MBSR and more recent clinically oriented hybrids such as MBCT and DBT, several other therapeutic interventions incorporating mindfulness meditation have been developed, including Acceptance and Commitment Therapy (ACT) (Hayes, Strosahl, et al., 1999) and Relapse Prevention (RP) (Marlatt, 1994; Marlatt & Gordon, 1985). But it was difficult for researchers to identify the precise mechanisms by which these interventions enabled patients to achieve success, primarily because they were integrative in nature and hindered the ability to analyze their particular active components (Loizzo & Blackhall, 1998). Other concerns were raised by Bishop (2002) who stated that there was no evidence that the use of MBSR increased the patients ability to reach a state of mindfulness. According to Bishop, these group interventions merely produced nonspecific benefits, such as self-efficacy and social support, or were corollaries of relaxation. Considering the demands of a meditation program and a daily practice, the author questioned if success rates were correlated with those preexisting personality traits of patients that influenced recruitment and compliance. According to Bishop, it is entirely possible that the efficacy of this approach has more to do with the kinds of people who gravitate to [this kind of] program than the [mindfulness] approach itself (p.76). Baer (2003) responded to some of these concerns providing several alternative mechanisms that could explain how mindfulness skills led to symptom reduction and behavioral change. She proposed the following five factors: (a) exposure, (b) cognitive change, (c) self-management, (d) 163

relaxation, and (f) acceptance. In addition to Baers list, Deikman (1971), J. Miller (1993), and Kelly (1996) provide three other mechanisms of clinical change including (g) deautomatization, (h) lifting repression, and (i) existential relief.

Exposure Exposure refers to the instruction given in mindfulness meditation to observe thoughts, emotions, and/or sensations nonjudgmentally and without reacting. In Kabat-Zinns (1982) early work, chronic pain patients were asked to focus their attention directly on pain sensations as well as secondary aversive cognitions and emotions. Despite their discomfort, patients began treating thoughts and emotions in a similar fashion rather than as directives and experiences to be either followed or avoided. Their ability to observe mind-body processes in this particular way over time reduced distress. By allowing and accepting events and experiences to continually arise, patients developed distress-tolerance and desensitized their compulsive and automatic reactivity. As Linehan (1993a) noted, fostering behaviors that neither avoided nor escaped particular reactions, extinguished the fear response and avoidance behavior previously elicited by these stimuli. This did not mean that their conditions were cured; but rather that their ability to live with these conditions without exacerbating them was increased. According to Baer (2003) prolonged exposure to the sensations of chronic pain, in the absence of catastrophic consequences, might lead to desensitization, with a reduction over time in the emotional responses elicited by the pain sensations. Thus the practice of 164

mindfulness skills could lead to the ability to experience pain sensations without excessive emotional reactivity. Even if pain sensations were not reduced, suffering and distress might be alleviated. (p. 128) She maintained that exposure was not a concept that was especially behavioral since developing tolerance and reducing emotional reactivity were common skills in all orientations. Baer (2003) noted, however, that in contrast to clinical strategies that required patients to induce and initiate symptoms in order to systematically desensitize them, mindfulness practitioners were asked to simply observe the flow of consciousness as it naturally arose.

Cognitive Change Cognitive change refers to the perceptual reorientation that is achieved through mindfulness meditation. Here the cognitive strategy in mindfulness does not resemble or correspond to conventional cognitive therapies, which attempt to reframe distorted thoughts, challenge irrational beliefs, replace negative schemas with positive affirmations, and distract attention away from negative thoughts. Mindfulness, on the other hand, transforms ones orientation towards the entire context of thinking rather toward any of its specific contents. In this sense, thoughts are treated as just thoughts, as opposed to their being viewed as reflections of reality or of truth. As a result, they do not necessitate the level of emotional and behavioral reactivity to which they would ordinarily have given rise. In Nat Hahns (1976) approach to mindfulness practice, practitioners were asked to view thoughts as clouds passing in the sky of 165

their mind, and then to return to observing the breath without following or attaching themselves to the clouds. In this way, depressogenic or anxious thought patterns lost their impact and did not become sources of obsession or anxiety. Therapeutically, this marked a shift away from individually correcting each thought distortion or belief; and, instead, addressed the manner in which individuals related to thought processes in general.

Self-management Self-management refers to the ability for mindful observation to provide a space between cognitive-affective stimulus and automatic behavioral responses, which permit individuals to implement coping skills and augment healthier interventions. In the present study, this space was previous discussed in terms of two key processes: deautomatization (Deikman, 1966; Rubin, 1991) and cognitive-affective uncoupling (KabatZinn, 1982). Epstein (1998) also referred to this process as unintegrating; in other words, as a process that allowed patients to let go and to find release from developing and reinforcing habitual cognitive, emotional, and behavioral patterns that resulted in dissatisfaction and mental anguish. Kristeller and Hallett (1999) found that women with binge eating disorders were able to improve recognition of binge urges as well as subtle satiety cues, affording them an opportunity to make healthier eating choices and to practice self-care strategies. Marlatt and Gordon (1985) made the identical observation with alcoholicsand by logical inference, patients struggling with substance abuse. According to Marlatt 166

and Gordon, mindfulness slowed automatic reactive patterns and allowed patients to maintain the necessary awareness to intervene with relapse prevention strategies before the urge to drink became overpowering. Linehens (1993b) observation of borderline populations also found that increased self-awareness and behavioral observation permitted the introduction of corrective responses, such as self-soothing tactics or an emergency phone call to their case worker immediately preceding the moment when emotions became unmanageable, triggering selfdestructive behavior.

Relaxation Relaxation refers to the capacity for all meditation regimens to lessen arousal through initiating parasympathetic activity (see Chapter 4 of the present study). Though mindfulness meditation is not exclusively designed to produce calm and relaxation, some of its basic practices (i.e., bare attention, awareness of the breath) have the ability to override stress reactivity, thereby decreasing the impact of medical illness and disorders. Though Bishop (2002) assumed that the benefits of mindfulness were correlated with relaxation, it is unlikely that this was the only reason that it worked.

Acceptance Acceptance refers to the ability to accept both pleasant and unpleasant states of being, the importance of which is frequently underestimated in current treatment approaches. Most conventional 167

therapies aim at change, correction, removal, or suppression of symptoms. On the other hand, according to Baer (2003), all of the mindfulness-based treatment programs that she reviewed included acceptance of pain, thoughts, feelings, urges, or other bodily, cognitive, emotional phenomena, without trying to change, escape or avoid them (p. 130). In order to highlight the distinction in approach, she used the example of patients with panic disorder. Such patients, in an attempt to avoid future panic attacks, often engage in maladaptive behaviors, such as drug or alcohol abuse, social isolation, and bodily hyper vigilance. Barlow (2001) noted that medication and CBT were the most desired and effective interventions for patients with this disorder. The aim of these two interventions was to chemically alter arousal pathways and to therapeutically mitigate the effects of panic-producing thoughts. The mindfulness method takes the opposite approach, fostering acceptance and receptivity towards panic attacks, which, though unpleasant, are time limited and not dangerous. By learning through mindfulness to continuously and directly face the consequences of attacks, patients are able to lessen their anxiety about them. Furthermore, harmful behaviors designed to avoid the experience of panic are decreased or abandoned. The emphasis of mindfulness on acceptance corresponds to the First Noble Truth within Buddhist metapsychology, that life is difficult, and by our very nature human beings are bound to experience sickness, pain, old age, and death. According to Nat Hahn (1976), from this perspective, ones afflictions become opportunities to disarm limiting emotions, such as fear and aversion, and accept a new way of being, as 168

well as embracing a kind of bare attention which sees things as they really are, as if for the first time (Harvey, 2000).

Deautomatization Deikman (1966a) coined the term deautomatization, which he defined as an increased flexibility of perceptual and emotional responses to the environment, resulting in the manifestation of previously imperceptible aspects of reality. He went on to state that mindfulness meditation was an attentional strategy that elicited such a reaction, serving as a regression to the perceptual and cognitive state of a child. This description is consistent with that of Zen Master Suzuki (1994), who suggested an optimal state known as beginners mind, where freedom was achieved through moment-to-moment receptivity toward reality, uncontaminated by previously conditioned perceptions. Deikman (1982) characterized this experience of beginners mind as consisting of five principles: intense realness and freshness, unusual sensations, unity, ineffability, and trans-sensate experiences. He defined trans-sensate experience as a state that went beyond customary pathways, ideas, and memories, the result of a new perceptual ability that responded to dimensions of the stimulus array that had been formerly disregarded or blocked from consciousness. In a later study, Deikman (1971) used the term deautomatization to describe the cognitive changes resulting from mindfulness meditation, brought about by the reinvestment of ones actions and precepts. He maintained that mindfulness meditation caused a shift toward a mode of 169

cognitive organization that preceded the analytic, abstract, and intellectual mode. He described this perceptual mode as being more vivid, sensuous, syncretic, animated, and dedifferentiated, with respect to the self/other dyad between objects and sense modalities. This process was also identified by Rubin (1991) who stated that meditation fostered the deautomatization of thought and action. Kabat-Zinn (1982, 1990) also stated that Buddhist practices such as mindfulness, bare attention, and zazen supplanted ones conditioned reactive, perceptual, and affective response patterns, resulting in a more direct moment-to-moment encounter with internal functioning and external activities.

Lifting Repression J. Miller (1993) focused on the lifting of repressed material and the unveiling of traumatic events during mindfulness meditation, describing three case reports in which patients uncovered traumatic memories and how mindfulness facilitated the process. According to J. Miller (1993), the nature and degree of the transformative experience depended to a great extent on the level of self-efficacy experience by the participant. However, all 3 individuals whom he studied saw their experiences as essential to their continued growth and healing; and none had any regrets about the unveiling that they underwent during their practice. Indeed, in spite of the intensity of their emotional suffering, all 3 chose to continue to practice meditation. In addition, J. Miller (1993) maintained that mindfulness meditation not only facilitated the emergence of unresolved material, but it also 170

helped practitioners to develop a detachment or disinvestment towards these events: Often repressed material surfaces with its original intensity. The instructions are to maintain a nonjudgmental awareness of this material, and observe the process of mind rather than the specific content. As mindfulness strengthens the meditator is able to face increasing more difficult material with calmness and equanimity. Similar to what often happens in psychotherapy [or in behavioral techniques like desensitization] previously repressed material continues to arise as the meditator becomes more skillful at working with it. (p. 171) The above case reports led J. Miller (1993) to conclude that mindfulness meditation could be potentially helpful as an adjunct to psychotherapy. He also discussed various integrative models, including self-oriented psychotherapy, which combined a regular mindfulness practice with less frequent psychotherapy sessions: This would reduce the cost of psychotherapy and very likely facilitate progress as unconscious material is unveiled in meditation. Of course, this model would not be appropriate for all individuals, especially for those who are at high risk for significant psychological distress through meditation practice. (p. 178)

Existential Relief Kelly (1996) reported on the benefits of meditative techniques in psychotherapy for patients who felt that their lives lacked meaning. These clients worked hard to gain material comforts and other indications of success; but instead of being happy and fulfilled, found themselves feeling disillusioned, empty, and depressed. As a direct correlate, Kelly noted that the three most commonly prescribed medications in America were anticular drugs, hypertensive drugs, and antidepressants. Despite the 171

trend of modern Western therapy to ignore spiritual concerns for those that they consider pragmatic, Kelly pointed out that such distinctions did not exist between the two domains. He maintained that the lack of fulfillment in peoples lives could not be separated from the myriad afflictions that they were addressing in therapy. At the same time, those in the helping professionals were usually ill-prepared or hesitant to deal with this lack of fulfillment. According to Kelly (1996), meditative approaches represent one route that is available to therapists for working on a variety of different levels with clients, ranging from the very practical, day to day concerns of stress and healthful living to the broader existential issues of purpose and meaning that might be considered to be part of spiritual well-being. (p. 41) Kelly (1996) noticed a growing trend in the patient population for treatments that considered the spiritual dimensions of life. He cited one study (Eisenberg et al., 1993) that reported that in 1992, one third of patients sought unconventional treatments. Eisenberg et al. (1993) also found that approximately one in four Americans used an unconventional treatment in conjunction with their physicians prescriptions. Among these unconventional therapies were meditation, prayer, homeopathy, mental imagery, yoga, and energy healing. This demand for alternative treatments that addressed issues ignored until recently provoked the mental health industry to more seriously consider approaches such as meditation. Lukoff et al. (1993) pointed out that at gatherings of the American Psychiatric Association and at other professional meetings, there was a growing number of presentations, workshops, and research

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focusing on transpersonal, spiritual, and existential aspects of clinical treatment. Kellys (1996) study focused on the potential effectiveness of, meditation in psychotherapy, concluding that the shifting paradigms of our culture and of the healing profession are creating new potentials for ancient, time-tested philosophies and practices to be blended with the relatively new techniques that psychotherapy has made available, yielding a more holistic and comprehensive perspective. (p. 46). Loizzo (2000) further supported this, stating that the recent National Institutes of Health (NIH) initiative to fund mind/body medical centers reflects the consensus that self-regulation techniques such as meditation are of proven value for many conditions and are vital to the future of medicine (p. 153). In his final discussion on the potential effects of mindfulness Bishop (2002) determined that there were more benefits than he had originally anticipated. He pointed out several unique qualities that mindfulness cultivated in patients, including a shift in perspective from automatically accepting the validity of thoughts and emotions to momentarily suspending judgment. He also noted a sense of nonstriving, which he described as a surrender or acknowledgement of the moment. No longer were patients trying to fight, change, or avoid the situation, or even to attempt to achieve another, more preferred experience. In this way, there was an emphasis on the immediacy of the current situation, rather than on the past or future. As the author summarized The voluntary deployment of attention, in combination with these attitudes, is thought to result in a heightened state of awareness in which one is conscious of a particular situation and ones cognitive, 173

emotional and somatic experience in a way that fosters a greater sense of equanimity. Thus, in addition to attentional regulation skills, mindfulness can be conceptualized in terms of a core set of attitudes and a general approach-orientation to experience. (p. 75) Meta-Analyses and Methodological Issues A number of literature reviews and meta-analyses (Baer 2003; Banadonna, 2003; Bishop 2002; Gremer et al., 2005; Grossman et al., 2004; Loizzo, 2000) have recently been conducted to review the efficacy of mindfulness-based interventions. By cross-referencing some of these sources it becomes possible to extract consistent findings, compare areas of disagreement, and synthesize recommendations for future research. Points of Comparison Between Meta-Analyses Inclusion Criteria Grossman et al. (2004), Baer (2003), and Bishop (2002) provided meta-analyses using standard methodological procedures, which they presented in reputed peer review journals. Each report indicated that there were numerous studies of mindfulness, yet few met the criteria for acceptable quality and relevance, and could not included in their evaluations. Most recently, Grossman et al. (2004) found 64 empirical studies on MBSR, but retained only 20 for their meta-analysis, including 10 that were well controlled, with the remaining studies relying on an intra group pre/post design. Their reasons cited for exclusion were (a) insufficient information provided as to the nature of the intervention; (b) poor quantitative health evaluation; (c) inadequate statistical analysis, such as effect size; (d) mindfulness not being the central component of the intervention; or, (e) the setting for the intervention deviating too widely from the original health-related context of MBSR. 174

Baers (2003) meta-analysis reviewed 21 reports on MBSR and MBCT, including 11 with control groups. Baer excluded studies on DBT, ACT, and RR because they failed to isolate mindfulness from the overall program effect. Bishop (2002) found 13 reports on MBSR and MBCT worthy of review at the time of his research, but only 4 were controlled clinical trials. All three meta-analyses cited methodological improvement as their primary recommendation for future mindfulness research with Bishop (2002) being far more critical in his discussion. Target Populations While many of the studies that were compiled and reviewed overlapped, they nevertheless revealed an impressive diversity of target populations and disorders to which mindfulness was applied (Baer, 2003; Bishop 2002; Grossman et al., 2004). Populations were categorized into four types: medical, psychiatric, mixed (medical and psychiatric), and nonclinical (i.e., students, healthcare providers, inmates, and general volunteers). The variety of dependent measures or disorders targeted according to the population included (a) medical illnesses: chronic pain, fibromyalgia, psoriasis, cancer, multiple sclerosis, hypertension, coronary artery disease, and epilepsy; (b) psychiatric disorders: anxiety, eating disorder, depressive disorder; and, (c) clinical issues: stress level, anger level, self-concept, self-esteem, ego-defense mechanisms, religiosity, locus of control, and general wellness. The following discussion presents general findings and conclusions drawn from these three meta-analyses.

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Mean Effect Size Grossman et al. (2004) found MBSR to be a useful intervention for a broad range of chronic disorders and problems, indicating that the consistent and relatively strong level of effect sizes across very different types of sample indicates that mindfulness training might enhance general features of coping with distress and disability in everyday life, as well as under more extraordinary conditions of serious disorder or stress. (p. 39) Specifically, they reported a mean effect size of almost 0.49 pertaining to six studies involving active control and a mean effect of 0.58 for four other studies employing waitlist control. While the authors cautioned readers not to generalize these findings, they responded to Bishops (2002) earlier concerns by controlling for the nonspecific effects of the mindfulness intervention program. Baer (2003) found mindfulness interventions to demonstrate statistically significant reductions in symptoms of pain, anxiety, depression, binge eating, and stress levels. After tallying the posttreatment scores for 15 independent studies and calculating the mean effect size, Baer found an overall mean of 0.74 (SD = 0.39). When each of these 15 effect sizes were weighted by sample size, the overall posttreatment effect size of mindfulness studies reviewed was 0.59, a comparable finding to Grossman et al.s (2004) waitlist control effect size. Thus, on the average, the literature review here suggests that mindfulness-based interventions have yielded at least medium-sized effects, with some effect sizes falling within the large range. Many of the effect sizes calculated for these studies are probably conservative. . . . (Baer 2003, p. 135) 176

Methodological Weaknesses Grossman et al. (2004) identified several methodological weaknesses in their review. The lack of follow-up data provided by most studies restricted analysis to more or less immediate effects. While there was research on the long-term effects of mindfulness on chronic pain (Kabat-Zinn et al., 1987; Randolph, Caldera, Tacone, & Gareak, 1999), anxiety (J. Miller et al., 1995), psoriasis (Kabat-Zinn, 1998), depressive relapse (Segal et al., 2002; Teasdale et al., 2000) and stress and mood in cancer patients (Carlson, Ursuliak, et al., 2001) the authors felt that much additional follow-up research is needed to confirm these and other benefits. Grossman et al. (2004) listed other major deficiencies, such as insufficient consideration or information was typically given about participant drop-out rate, other concurrent interventions during the mindfulness training period, therapist adherence to intervention program, evaluation of therapist training and competence, descriptions of interventions, adequate statistical power to calculate intervention effects, or the clinical relevance of results. Additionally, the construct of mindfulness itself, although central to all interventions, was neither operationalized nor evaluated for change in the study. (p. 40) In her review, Baer (2003) also summarized several methodological weaknesses, beginning with the lack of active control groups. Most studies on mindfulness used an intra-group, pre/post design that did not control for the passage of time, or demand characteristics, placebo effects, or comparison with other interventions. Many studies used too small a sample size. Baer recommended that future research should include at least 33 participants to statistically achieve a medium-to-large treatment effect. 177

She also found little-to-no control for integrity and consistency in the delivery of the intervention. Only one report (Teasdale et al., 2000) described methods for monitoring how instructors train in and deliver the MBCT protocol and interventions. Mindfulness programs require their instructors to undergo extensive training and supervision; the omission of these details and methods of accountability makes it difficult to isolate quality of the instruction from the overall effect. Finally, according to Baer, clinical significance is typically undetermined. While statistically an intra group difference can indicate a post treatment effect, it is important for symptom reductions to be compared with normal ranges in the general population on relevant dependent variables. Bishop (2002) provided the most critical appraisal of the research methods used in several of the mindfulness studies discussed by Grossman et al. (2004) and Baer (2003). For example, Shapiro et al. (1998) examined the effects of MBSR on levels of stress and dysphoria in a medical student population and determined it to be effective in lowering symptoms after an 8-week intervention. While matched randomization and replication of the study with a control group eliminated confounding variables and provided additional data for intervention-efficacy, Bishop pointed out the limitations of using an inactive control group. Since nonspecific factors such as therapists attention, social support and positive expectancy can improve outcome it is difficult to attribute the changes to the specifics of MBSR (p. 72).

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Bishop (2002) referred to Speca et al. (2000) whose study achieved reductions of 65% of mood disturbance and 35% of stress symptoms in a mixed-cancer patient population following MBSR. According to Bishop, it is not possible to rule out social desirability effects that may have been operative in patients reports of mood and stress changes or their reports of treatment compliance (p. 72). Finally, Bishop stated that Teasdale et al. (2000), in their study of MBCT for depressive relapse prevention, offered the most rigorous study to date. This study included randomization, active control group, sufficient sample size and 6-month follow up. Those interested in producing a mindfulness study in the future are advised to follow these methodological provisions closely. However, Bishop asserted that the Teasdale et al. (2000) study failed to isolate the effect of mindfulness meditation from cognitive therapy, and cautioned against making strong statements regarding the effectiveness of meditation per se. Defending the criticism that most studies involving mindfulness failed to use rigorous control designs, Lazar (2005) maintained that there was difficulty in creating a control intervention that adequately matches the core elements of mindfulness practice. For example, to make a controlled study of MBSR, we would require an 8-week group format, with 40 minutes of daily homework that is compelling enough to get participants to comply, but has no therapeutic value. (p. 222) Potential Benefits There is a general consensus in the literature regarding the efficacy of mindfulness-based interventions; and future researchers are 179

encouraged to continue, although with more stringent methodologies. Grossman et al. (2004) stated that the literature seems to slant toward support for basic hypotheses concerning the effects of mindfulness on mental and physical wellbeing. Mindfulness training may be an intervention with potential for helping many to learn to deal with chronic disease and stress. (p. 40) Similarly, Bishop (2002) concluded his study by stating that MBSR promised to offer a potentially effective treatment option that could help some patients to manage their stress and mood symptoms in the face of their illness. Baer (2003) agreed with Bishop and summarized her review findings by stating that in spite of the methodological flaws, the current literature suggests that mindfulness-based interventions may help alleviate a variety of mental health problems and improve psychological functioning. These studies also suggest that many patients who enroll in mindfulness-based programs will complete them, in spite of high demands for homework practice, and that a substantial subset will continue to practice mindfulness skills long after the treatment program has ended. (p. 139) Baer (2003) also reviewed criteria set out by the Division 12 Task Force on Promotion and Dissemination of Psychological Procedures. In her estimation MBSR and MBCT both met the criteria for designation as probably efficacious because these interventions proved to be more effective than a waitlist control group or another treatment in two or more clinical trials. With careful attention paid to methodological issues in future research, it may not be long before mindfulness-based interventions will be seen as having a greater capacity to help people than the approaches currently used in todays field. What seems clear for now is that while researchers and clinicians are aware of the health benefits of mindfulness 180

meditation, more independent, full-scale clinical trials with significant results are required in order to shape the policy and dissemination of this technique. With the pervasive use of mindfulness imminent, serious questions arise regarding how health care provides should preserve the integrity of, train in, adequately deliver and ethically be supervised in this technique.

Summary The chapter explored the differences between Buddhist and conventional psychology, with particular emphasis on the effects that each, mindfulness meditation and psychotherapy, have on ego structure and development. It was shown that historically the literature endorsed a sequential model in which psychotherapy precedes meditation practice, although currently Buddhist-oriented clinicians have made a strong argument for a simulations approach to treatment. The research reviewed contraindications and adverse effects of mindfulness practice and then complemented this with recent clinical outcome studies supporting its efficacy for a wide range of mental health issues. The research findings of mindfulness from the various Buddhist, scientific and clinical perspectives reviewed to this point will now be further integrated and synthesized.

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CHAPTER 7: INTEGRATION AND SYNTHESIS The above review has focused on three areas of research in the literature: First, the theory, application, and effects of mindfulness meditation as presented in its traditional context in Buddhist psychology; second, the extensive empirical research conducted over the last 50 years, including studies that addressed the physiological, neurological, and psychological effects of mindfulness meditation; and third, clinical studies and evidence regarding the efficacy of mindfulness meditation as a treatment intervention for a wide variety of medical and mental heath issues. This chapter integrates and synthesizes findings regarding mindfulness meditation in order to provide a coherent perspective of its effects and benefits. The Central Role of Disidentification In reviewing the research several causal mechanisms of mindfulness were seen as cornerstones of clinical change and healing, the most crucial being the process of disidentification. Descriptions and definitions regarding this process have differed greatly. Buddhist sources used stabilized meditative analysis to disidentify from the erroneous attachment and reification of self. Western applications of mindfulness typically did not extend to its advanced stages of analysis of the observer; rather they focused on disidentifying from problematic thoughts, emotions and behaviors. As an example, Kabat-Zinn et al. (1987) found that mindfulness meditation 182

evokes a new pattern of perceiving based on intentionally paying attention in a moment-to-moment mode. It is thus potentially applicable to a wide range of human activities and experiences. Mindfulness meditation can be thought of as a generalized reference-frame shift from partial awareness (an automatic pilot mode of functioning) to moment-to-moment awareness with a nonjudgmental, witnessing quality. . . . There are strong theoretical and practical reasons which suggest that a learned and intentional use of moment-to-moment awareness can have a profound effect on pain perception, the experience of suffering, and on stress reactivity. (p. 171) Deikman (1982) called this process deautomatization, and defined it as the undoing of the automatic processes that control perception and cognition (p. 137). Alternative terms proposed in the West for this process included cognitive distancing, deliteralization (Hayes, Strosahl, et al., 1999), decentered perspective, metacognitive awareness (Teasdale, 1999; Teasdale et al., 1995), unintegration (Epstein, 1998), manual-override (Loizzo, 2004), and cognitive-affective uncoupling (Kabat-Zinn, 1982). What follows is an integration of findings from the literature based on the notion of disidentification. Disidentification in Buddhist Meditation The aim of Buddhist mindfulness meditation is to foster the ability to disengage from habitual reactive patterns of thinking and feeling, and ultimately to disidentify from notions of a reified self rooted within those patterns (Gyatso, 2000). Once disidentified in this way, the individual is able to tolerate the physical and mental difficulties that occur in life, rather than react with attachment and aversion against them. Loizzo (2004, 2006b) determined that conscious self-regulation and cognitive-affective-

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behavioral learning are the active agents associated with the process of disidentification that lay at the heart of the Four Noble Truths. The Buddhist Four Noble Truth medical model traces the causes of human suffering to the unconscious impulses of fear-based attachment and defensive-hostility rooted in reified-self habit (Loizzo, 1999). Recent empirical studies suggested that toxic emotions (Goleman, 2003a, 2003b) including anger (Harmon-Jones, 2004; Harmon-Jones, & Allen, 1998; Ornish et al., 1990), hostility (Williams, 1989), and self-involvement (Graham et al., 1989; Scherwitz et al., 1986) had a greater correlation to mortality than coronary artery disease, high cholesterol, high blood pressure, smoking, and diet. These studies supported the ancient Buddhist mind science that underscores the significant role played by an individuals outlooks, attitudes, and behavior on his or her health. In contrast to the current Western allopathic and bio-medical models of disease, based on 19th-century Cartesian dualism, Buddhist psychology is based on a nondual, mind/body paradigm, which utilizes the power of the mind to affect the brain and vice versa. This result is a new emphasis on the innate potential of individuals to promote their own health and healing. The Buddhist therapeutic curriculum consists of three higher trainings (adhisiksya): 1) behavioral discipline, 2) attentional-control, and 3) experiential insight. Each of these works in tandem to reciprocally inhibit the destructive forces of the three corresponding impulses, of attachment, aversion, and misknowledge. Loizzo (2004) recommends that the Buddhist curriculum of the three higher training not be conceived of 184

linearly, as if one phase of training eliminates its corresponding types of defilements before progressing to the next phase of training. Rather the trainings are different methods that correspond to the increasingly delicate dimensions consciousness along a continuum, and should be viewed holistically or cyclically. Depending on ones state of consciousness, one can attend to defilements on the external level, internal level or most subtle level. Over a period of time, one organically vacillates from behavioral modification to mental/cognitive reframing to reprogramming the unconscious conditioning, and back again. In this way, the three higher trainings work cyclically in support of each other. For example, corrective lifestyle and behavior changes afford individuals greater attentional control and concentration. Classical Buddhist behavior modification, detailed in the Monastic Code of Discipline (Skt Pratimoksha; Pali Patimokkha:) found in the Sutta-vibhanga (Stv) of the Vinaya-pitaka (Vp), begins with five laymans vows consisting of abstaining from killing, stealing, lying, sexual misconduct and the taking of intoxicants. Such behavioral adjustments consequently lead to a still and peaceful mind and provide the prerequisite mental stabilization to analyze and subvert unconscious self-reification habits. Reciprocally, as unconscious tendencies are extinguished and selflessness (anatman) becomes actualized, ones behavior naturally changes in a positive learning feedback-loop. When individuals begin to see themselves and reality more realistically, their mental state becomes more joyful, content,

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and tranquil and their behaviors consequently are altruistic and generous (De Silva 2000; U Pandita, 1991). As Goleman (1976) indicates the three higher trainings (adhisiksya) correct unrealistic behaviors, attitudes and outlooks by introducing and systematically reinforcing their opposite, more healthy correlates in a process known as reciprocal inhibition. This corrective learning takes place on three levels: conceptually through education, reflectively through discussion and contemplation, and experientially through meditation and rehearsal (sadhana) (Loizzo, 2004). Mindfulness meditation is thus a multilevel, cognitive-affectivebehavioral, self-regulatory intervention. It can be used to reprogram conditioned and instinctual reactive patterns by introducing new modes of responsiveness based on refined awareness and acceptance. The study showed that mindful awareness and analytic insight can enable individuals to learn how to perceive the impermanent, relative, and dissatisfying nature of attachment to self and phenomena, and thus align themselves with, rather than against, the ebb and flow of reality (Loizzo, 2000, 2006b; Thurman, 1991). In current Western terminology, the three higher trainings are aimed at lifelong learning, preventive health education, and sustainable lifestyle changes, rather than short-term, disease-specific, mechanistic interventions. A body of literature (Gould et al., 1995; Ornish et al., 1990, 1998) demonstrated that a comprehensive lifestyle change based on an Asian mind/body approach could not only arrest the development of coronary artery disease but actually reverse it. These authors indicated 186

that in some cases, medications and the latest surgical interventions were only able to temporarily maintain the progression of disease. Selfless attitudes, positive emotions and the capacity to disidentify from thoughts and emotions were thus seen as essential features of recovery and health promotion.

Disidentification in Mind/Body Medicine Studies in mind/body medicine found that mindfulness meditation elicited the relaxation response, counteracting autonomic fight-flight patterns, and decreasing stress-exacerbated medical symptoms (Benson, 1975, 1992). According to Teasdale et al. (1995), mindfulness led to increased physical well-being by enabling individuals to transform their relationship to medical illness; and from this disidentified perspective, they could learn how to reprogram their affective response patterns and be able to approach situations with objective awareness. Thus, a given situation or context was freed from seemingly inherent, negatively perceived values, resulting in decreased emotional reactivity (Bishop, 2002). Kabat-Zinns (1982, 1990) research also reported on the process of disidentifying by attributing to mindfulness meditation the capacity to disrupt the fight-flight reactions in anxiety-provoking situations, allowing for effective responses rather than enactments involving anger, fear, or panic. Other researchers (Baer, 2003; Breslin, Zack, & McMain, 2002; Loizzo, 2004), similarly showed that mindfulness meditation could help individuals by offering a variety of healthy and appropriate coping 187

strategies based on disidentification with thoughts, emotions and behaviors. The results of these so-called shifts in frame of reference: (a) enabled practitioners to sustain the attention required for demanding tasks, (b) helped them to retain the cognitive ability for learning and problem solving, (c) taught them how to communicate and empathize with others, and (d) gave them an increased sense of self-efficacy and autonomy. Although it was seen that most meditation practices focused on eliciting a relaxation response, mindfulness meditation sought to decrease sympathetic activity in order that individuals might establish an ideal, internal environment for cognitive-affective learning and behavioral change (Loizzo, 2006b). Studies indicated that mindfulness meditation was able to interrupt cycles of negative internal experiences, such as anticipatory anxiety of future events, or depressive rumination of past events. This was based on the idea that through this practice and resulting disidentification, individuals could regard their beliefs as habits of thinking, feeling, and perceiving (Tart, 2003) rather than as objective realities. Mindfulness meditation thus enabled individuals to perceive that it was their beliefs that determined the manner in which they observed and interacted with their environment, and they could observe the potential consequences. As a result, habitual and destructive ways of reacting were replaced with intentional, adaptive, and constructive ways of responding (Breslin et al., 2002; Hayes, 2002a, 2004), thereby increasing their coping skills.

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Disidentification in Neuroscience Research from the field of cognitive neuroscience indicated that mindfulness fostered disidentification by blocking alpha activity, and priming the brain to be acutely receptive to sensory input (Lo et al., 2003). Not only was a state of relaxed alertness brought about, but as the Davidson et al. (2003) study indicated, mindfulness also produced greater levels of left-sided activation of anterior regions in the brain, regions associated with decreased anxiety and increased positive affect. A high correlation between left-side brain activity and increased immune function was found, suggesting that positive emotion was one of the mechanisms underlying stress-hardiness and the improvement of immunity (Davidson & Irwin, 1999). This finding was consistent with that of neuroplasticity research, that the creation of an enriched (stimulating and pleasurable) environment promoted neural repair, growth, and change (Rosenzweig & Bennett, 1996; Swaab, 1991). It was thus seen how significant were the implications of a feedback loop in which brain matter and function were altered through intention and positive emotion, and reinforced through meditative training, both of which are still novel and controversial concepts in the field of meditation research.

Disidentification in Psychotherapy In the review of the psychology literature mindfulness was found to foster disidentification in terms of a cognitive-affective process of interoceptive exposure, desensitization, and extinction (Hayes, 2002a, 2002b, 2004). During mindfulness training, participants exposed to a series 189

of threatening or near-intolerable stimuli were able to develop a sustained and nonjudgmental awareness of these uncomfortable psychological experiences which included thoughts, affects, and physical sensations (Baer, 2003; Hayes & Wilson, 2003). The prolonged observation of uncomfortable experiences then further induced participants to lessen their emotional avoidance of previously unacceptable stimuli. This ability was based on the concept of desensitization proposed in cognitivebehavioral psychology (Barlow, 2001; Hayes, 1987). It was thus seen that mindfulness enabled individuals to re-parent themselves, to self-regulate affect, to learn positive responses based on present-moment awareness and acceptance, and to override conditioned reactions based on avoidance, fear, and hostility (Breslin et al., 2002; Hayes, 1994). In addition, mind/body therapies and mindfulness-based educational programs have consistently been found to be advantageous to Western patients, whether as an adjunct to allopathic treatments or in place of such conventional interventions. An added incentive that was discussed was that meditation instruction and supervision could be delivered at a fraction of the emotional and financial cost of conventional medicine and invasive surgeries (Goleman & Gurin, 1993; Kabat-Zinn, 1990). Buddhism and Psychology Reconsidered The aim of mindfulness meditation is to provide insight into the impermanent (anicca), insubstantial (anatman), and dissatisfying (dukkha) nature of phenomena. It can lead to the deregulation of reinforced negative habit patterns and unhealthy affects. Deeply rooted impulses 190

(kleshas), also conceptualized as libidinal drives (fear-based attachment, hostility, defensive alienation) and compulsive behaviors (karma), are brought under conscious observation and disidentified from through penetrative self-analysis. The Buddhist therapeutic curriculum of the three higher trainings (adhishiksha) cultivates disciplinary intentions (sila) and empathic behavior to counteract clinging, and cultivates meditative equilibrium (samadhi) and tolerance to counteract anger and other adversive mental states. The curriculum also cultivates insight (prajna) to counteract alienation and selfpreoccupation by developing a realistic outlook that perceives our universal interconnectivity. In his groundbreaking report, Loizzo (2000) stated compellingly that the extensive synthesis of various therapeutic paradigms made the Buddhist meditative system the oldest and most comprehensive integrative psychology in world history. As discussed in Chapter 3, these three major paradigms include: the Individual Vehicle tradition (Hinayana), the Social Vehicle tradition (Mahayana), and the Adamantine Vehicle tradition (Vajrayana). Loizzo (2004) pointed out that the integrative nature and sophistication of Buddhist meditative practice explains why it has been compared to so many divergent psychotherapeutic techniques (Benson, 1976; Epstein, 1995; Kabat-Zinn, 1982; Linehan, 1993a, 1993b; Mikulas, 1978, 1981). Loizzo (2000) provided

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the following method of synthesis between traditional Buddhist, and conventional Western, psychotherapies. In the Individual Vehicle tradition, prevalent in Southeast Asia, vipassana is practiced with an attitude of renunciation and is akin to cognitive behavioral therapies. Practitioners view behavior as ingrained by habitual action (karma) and reinforced by conditioning, yet modifiable by learning. Such a view is also akin to classic dynamic psychotherapy because it recognizes that cognitive and emotional defenses, deeply rooted in evolutionary egocentric instincts, hinder the growth process. In the Social Vehicle tradition, prevalent in East Asia, vipassana is practiced with a nondual attitude of universal responsibility (bodhicitta). It is similar to an object-relations approach since it emphasizes social connections, reinforces healthy emotions, and locates development within a naturally constructive social field. In the Adamantine Vehicle tradition, prevalent in Tibet, vipassana is practiced with an impassioned and creative attitude. Similar to Jungian and Reichian therapies, such meditation involves meditatively projecting and internalizing idealized self-images based on visualization archetypes (yidam). In its highest stages, it uses sexual arousal and euphoria to disarm behavioral defenses and to enhance mind/body openness. Here the relationship with, and introject of, the spiritual teacher (guru yoga) plays a central role, as positive transference with a highly trained adept is conjoined with self-analysis (Loizzo 2000). 192

In the process of acquiring meditative skill, meditators reprogram basic patterns of perception, cognition and behavior. As this reprogramming takes root they undergo a fundamental transformation of the brain, nervous system, and personality (Loizzo, 2006b). The net effect of mindfulness and analytic insight meditations are the deconditioning of habitual response patterns, particularly the root cause, the defensive selfhabit, which, when they are once dissolved, free the individual to experience boundless joy (sukkha), compassion (karuna) and skillful craft (upaya) in teaching others how to free themselves. Current empirical research has shown that, as an integrative technique, mindfulness meditation has the potential to greatly complement cognitive neuroscience, mind/body medicine, and psychotherapy by addressing aspects often neglected by conventional Western approaches. What is less evident in the Western empirical literature is that mindfulness meditation is grounded in a different cultural context, primarily that of Asia, and is embedded in its own sophisticated, comprehensive and time-tested psychological system. This system expounds a far greater potential for health and wellness than the Western research thus far has been able to indicate. In the advancement of Western healthcare, Buddhist psychology with its refined techniques of mindfulness meditation and self-healing, have much to offer. And so this study has shown that popular demand and professional receptivity towards integrative approaches are todays 193

current trend in the field, and that mindfulness meditation represents a cutting edge technique poised to become a more widely accepted intervention (Baer, 2003). CHAPTER 8: CONCLUSION My objective in the present study was to examine and integrate perspectives on the practice of mindfulness meditation from the areas of Buddhism, medicine, neuroscience, and clinical psychology. I undertook this project with the understanding that there has been a burgeoning awareness among Western therapists, psychologists, and scholars, that mental and physical health is contingent upon sustainable lifestyle changes. This growing perception has contributed to an increase in the study of Asian mind/body therapies that are time-tested in producing cognitive-affective-behavioral insight and transformation (Loizzo, 2004, 2006b). In addition, managed care and the demand of Health Maintenance Organizations (HMO) for empirically validated, noninvasive, timeefficient, and cost-effective health care alternatives have fueled a renaissance of integrative and complementary treatments that meet these standards (Dimidjian & Linehan, 2003). In response to public interest and systemic need, currently there has been vigorous professional research on the neuro-biological effects, clinical applications and evidence-based efficacy of various meditation techniques, in particular, the ancient Buddhist method of mindfulness (sati) (Baer, 2003; Banadonna, 2003; Bishop, 2002; Brown & Ryan, 2003, 2004; Gremer et al., 2005; Grossman et al., 2004; Hirst, 2003; Loizzo, 2000). 194

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Recommendations for Future Research Methodological Rigor The primary recommendation regarding future research in the area of mindfulness meditation is that of greater methodological rigor. Though Western meditation research has been conducted for more than 50 years, there needs to be a greater number of well controlled, full scale clinical trials to further validate initial findings of preliminary reports (Baer, 2003; Bishop, 2002; Feldman et al., 2004). In their meta-analysis, Grossman et al. (2004) reviewed over 60 studies on mindfulness but retained only 20 because of the lack of methodological accuracy. There are a few noteworthy examples of reliable meditation research, such as Teasdale et al. (2000) and Davidson et al. (2003), which could serve as standards for future projects. Specific Areas to Be Addressed Future research in the field of mindfulness meditation research should consider the following methodological issues to be of primary importance: 1. An operationalized definition of mindfulness and an explicit reference to the type of meditation practice being studied would provide clarity and cohesion. In this way, the subjects and the findings of the research could be organized into consistent classifications according to their typology. 2. A clear indication would be helpful as to which meditation-based intervention program was used (i.e., MBSR, MBCT, DBT, etc.). Such an indication would present a breakdown of the length of the 196

course, duration, frequency of the practice, and if extensive retreats were included. These would eliminate any confusing variables associated with divergent protocols. 3. Outcome measures, derived from standardized and validated scales, need to be established with consistency so that data can be reliably determined. 4. Use of a scale that measured the specific development of skill in mindfulness would help in quantifying the dose response, and assist in correlation analysis to isolate its effect. Examples of the scales include the Freiburg Mindfulness Inventory (Buchheld, Grossman, & Walach, 2001), the Mindful Attention Awareness Scale (Brown & Ryan, 2003), the Toronto Mindfulness Scale (Bishop et al., 2003), the Kentucky Inventory of Mindfulness Skills (Baer, Smith, & Allen, 2004), and the Cognitive and Affective Mindfulness Scale-Revised (Feldman, Hayes, Kumar, & Greeson, 2003, 2004). 5. The collection and provision of data for all preintervention and postintervention measures would permit researchers to calculate the mean effect size for variables. 6. A control group would be useful for researchers in isolating the nonspecific effects of meditation, including social support, demand characteristics, and expectancy effects. 7. Postintervention data and follow-up at 6 months or more would provide a much needed longitudinal perspective regarding meditation adherence and long-term effects.

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8. Specific information regarding the training and background of the meditation teacher or facilitator would help to clarify their variables from those of their subjects. In this way, personal and

professional traits that could influence program outcome would be isolated. experience, any Such influences would include years of meditation specifics regarding meditation tradition and training, and

deviations they made from the meditation protocol. A large scale study involving an expert meditation master from a particular Asian meditation tradition (South East Asian, Indo-Tibetan Buddhist or Hindu Yoga) has yet to be conducted.

9. Sample sizes that involved at least 30 participants could provide more statistically significant effect sizes of medium or greater. 10. The maintenance of thorough records of the participants psychosocial history would augment any future developments of a profile of meditation suitability. 11. Studies examining the effects of mindfulness meditation on medical and clinical populations are in need of replication, but should be complemented by research on healthy nonclinical samples in order to understand its full potential and benefit. Qualitative Data and Subjective Accounts In addition to the above recommendations, given the scarcity of subjective accounts of meditative experiences found in association with the empirical literature, quantitative and experimental studies need to be more fully complemented with sound qualitative or mixed methodological designs. Such components as interviews, subjective 198

reports, personal experiences, and open-ended questionnaires need to be addressed as a way to increase the scope of available information. Some researchers have conducted such qualitative and mix-design studies and found that the qualitative aspects of the studies added substantively to the information gained solely from the quantitative elements (Carlson et al., 2001; Mason & Hargreaves, 2001). While quantitative reports indicated that an actual effect was achieved, qualitative reports revealed specifics regarding the manner and mechanisms by which this effect occurred. These were seen to be significant areas of contribution, since the precise mechanisms underlying mindfulness were still largely misunderstood (Baer, 2003). This subjective component has the capacity to bridge the gap between the cross-cultural, methodological approach of Western empirical objectivity, on the one hand, and Buddhist notion of valid cognition (pramana), or first-person-objectivity, on the other. In the traditional Buddhist context, according to ancient cartographies of consciousness, subjective accounts of inner experience are an essential component of meditation training, particularly for verifying mental development. Such first-person accounts allow the meditation mentor/teacher (guru) to assess and validate the psycho-spiritual achievement or regression of the practitioner (B.A. Wallace, 2003). Further Implications Secular Versus Traditional Meditation Most investigations of mindfulness meditation in the West, particularly in the contexts of health and clinical applications, have 199

involved the use of secularized versions, in which traditional spiritual aspects have been removed. The consequences of secularizing meditation practices, specifically of separating mindfulness meditation from its Buddhist origins, have not been addressed adequately. How would the presentation of mindfulness meditation change if the cultural and spiritual origins were preserved? What might be gained in efficacy by doing so or by not doing so? Is our responsibility to provide a secular technique to the masses or to respect the ancient manner in which the technique has been preserved for millennia? Is there a rationale and necessity for both approaches to be available in the area of health and clinical services? These are central issues that follow from the purpose and tenets of this studythe examination of the origins of mindfulness meditation and the potential for its reintegration in the Western context. It is proposed here that, in order to address these questions, research into traditional Buddhist meditation techniques that have not been diluted or secularized when integrated into Western applications, such as MBSR and MBCT, may reveal significant features that have been previously neglected. Qualifications of the Clinician The use of mindfulness meditation in healthcare leads to questions regarding the clinicians proficiency, competency, and training in its applications, either secular or traditional. This question is significant, given that meditation practices largely originate in nonwestern spiritual traditions, such as Hindu yoga and Southeast Asian and Indo-Tibetan Buddhism. Who will train Western clinicians how to use these different 200

techniques? According to what standards and guidelines will clinicians be taught meditation techniques to integrate in their clinical practice? How will clinicians be monitored and to whom will they be accountable for using these new techniques appropriately? Will there be separate training and standards for secular and spiritually informed meditation applications? If we closely examine clinical studies on meditation, it is not clear what level of training and proficiency those providing instruction to patients have achieved. There has not been a single study conducted by a so-called master of an Asian meditation tradition, lineage or technique, although preliminary efforts are underway to address this need (Santa Barbara Institute for Consciousness Studies, 2005). While these areas have not been sufficiently addressed, researchers have posed questions regarding the clinicians ability to successfully convey meditation instructions, particularly when they involve a spiritual dimension (Dimidjian & Linehan, 2003; Roemer & Orsillo, 2003). In order to evaluate these professional and practice issues, the current study proposes that there should be a dialogue between clinicians in the West and Buddhist meditation adepts, those individuals who exhibit the most advanced meditative skills and accomplishments, as well as scholars of traditional Buddhist psychology who are expert regarding its theory and approach. Such a colloquy should include mutual exchanges and inquiries in the areas of theory, clinical application and empirical investigation to assist in clarifying the optimal ranges of meditative potential for health and healing and for clinical training and standards. 201

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Reintegration: A Return to Buddhist Origins In some circles, there has been growing progress made in the study of the Buddhist origins of mindfulness meditation and how it can be applied to Western healthcare. During the last 2 decades, the Mind/Life Institute has hosted a forum for dialogue between His Holiness the Dalai Lama and prominent Western scientists and clinicians (Davidson & Harrington, 2001; Goleman, 2003a, 2003b; Gyatso, 1997; Gyatso et al., 1991; Hayward & Varela, 2001; Houshmand et al., 1999; Zojonc, 2004). This forum has promoted a convergence of interest regarding techniques for health and healing, cross-cultural research collaboration utilizing distinct methodologies of meditation and neuroscience, as well as fostering a spirit of mutual respect and human discovery. Members of the Mind/Life Institute research consortium are currently involved in three major studies examining the long-term effects of traditional Buddhist meditation practices with large, nonclinical samples of healthy people in the West. These studies include the Shamata Project led by B.A. Wallace, evaluating long-term trait effects of concentration or quiescence meditation on adults in an intensive year-long meditation retreat; the Cultivating Emotional Balance Project led by Kemeny and Ekman, examining the effects of compassion meditation on healthcare providers; and, the UCLAs Mindful Attention Program (MAP) Project, co-investigated by B.A. Wallace, examining the effects of mindfulness meditation on attention deficit hyperactivity disorder in 203

children, adolescence, and adults. The Santa Barbara Institute for Consciousness Studies (2006), founded and directed by B.A. Wallace, provided the following rationale for these innovative projects by highlighting the limitations of previous research: Over the past 30 years there have been numerous studies of the psychological and physiological effects of meditation training, but most of such studies have been based on fairly simple pre/post (rather than longitudinal) research designs; focused on state rather than trait (i.e., long-lasting) changes in mental abilities; focused on physiological changes, such as indicators of relaxation, rather than cognitive, sensorimotor, neurological, emotional, and ethical changes; and were conducted before the advent of contemporary social-cognitive and brain-imaging techniques, which allow researchers to track changes in the mind and brain associated with meditation training. In addition, the meditation techniques under study were often not firmly grounded in a deep understanding of ancient meditation traditions and not conducted over an adequate period of time by an experienced instructor. For these reasons, we still do not know a great deal about how professionally administered meditation training of a particular kind, followed over an extended period of time (as is common in the traditions from which the meditation techniques are drawn), affects attentional, sensorimotor, and emotion-regulation skills or ethical responses to human suffering. (par. 2) There is a growing interest in the traditional Buddhist mind sciences and technologies among larger and more mainstream academic audiences. In a speech that His Holiness the Dalia Lama (Gyatso, 2005) presented to the Society of Neuroscience, he commented that the convergence of Buddhism and modern health sciences had the potential to make a significant contribution to human understanding. His Holiness stated that this combined approach would enable scientists, physicians, and scholars to further probe the complex inner world of subjective experiences and lead to advances in cure and treatment. He mentioned 204

studies in which mindfulness training and Buddhist compassion practices, done on a regular basis, were bringing about changes in the human brain, which were correlated to positive mental states and which could be observed and measured. The Dalai Lama remarked Already the benefits of such collaborations are beginning to be demonstrated. According to preliminary reports, the effects of mental training, such as simple mindfulness practice on a regular basis or the deliberate cultivation of compassion as developed in Buddhism, in bringing about observable changes in the human brain correlated to positive mental states can be measured. Recent discoveries in neuroscience have demonstrated the innate plasticity of the brain, both in terms of synaptic connections and birth of new neurons, as a result of exposure to external stimuli, such as voluntary physical exercise and an enriched environment. (Gyatso, 2005, para. 9) Furthermore, His Holiness referred to the Buddhist contemplative tradition as having the ability to expand the Western field of scientific inquiry by proposing types of mental training that could also evoke neuroplasticity. If it turns out, as the Buddhist tradition implies, that mental practice can effect observable synaptic and neural changes in the brain, this could have far-reaching implications (Gyatso, 2005, para. 9). The repercussions of such research would not be limited only to the growth of awareness regarding the human mind; they could have great significance in the fields of education and mental health. In the same way, the Dalai Lama found that Buddhist compassion had the capacity to lead practitioners to a radical shift in outlook and to greater empathy toward others, changes that offered far-reaching implications for society as a whole. With the wider influence of Buddhism on popular culture and 205

professional practice, we may expect to see adaptations in education and training of those assigned to provide complementary healthcare services. Dr. Joseph Loizzo, founding director of the Nalanda Institute for Meditation and Healing in New York, represents a possible prototype for the integrative health care practitioner of the future. A psychiatrist and Ph.D. Buddhist scholar, Loizzo combines advanced academic training and practice in two healing disciplines. Loizzos study of Buddhist philosophy, meditation practices and Tibetan medicine, were based on first hand knowledge of the original Sanskrit and Tibetan scriptures and texts and was conducted within the context of close mentoring with adept scholars of the Buddhist tradition. This knowledge base was combined with conventional training in Western medicine, psychiatry and psychotherapy to create a unique synthesis that respects and maximizes both traditions equally. After 30 years of research, Loizzo (2004) developed a meditation manual consisting of a 24-week program of mindfulness meditation and visualization techniques adapted directly from original Indo-Tibetan Buddhist sources. These techniques are geared toward the cultivation of cognitive-affect-behavioral learning and positive lifestyle changes for Western medical populations and healthy, progress-oriented clients alike. Unique to the program is the study, reflection and meditation practice of selflessness, based on the so-called four-key analysis originally developed by the venerated 14th-century Tibetan scholar Tsong Khapa, and available 206

in a translation by Hopkins (Tsong Khapa, 1977). Loizzo et al. (2004), at the Center for Integrative and Complementary Medicine at the WeillCornell Medical Center in New York City, conducted a pilot study in which they examined the effects of this program on quality of life in a breast cancer patient population. The preliminary data revealed significant results in terms of symptom reduction and lifestyle improvement, and Loizzo and colleagues have been awarded an additional $250,000 grant by Avon to continue with a large scale clinical trail. Loizzos (2004) intervention program represented a departure from all other previous meditation-based protocols (Hayes, Strosahl, et al., 1999; Kabat-Zinn, 1982; Linehan, 1993b; Marlatt & Gordon, 1985; Segal et al., 2002). Dr. Loizzo is the first to propose a completely traditional Tibetan Buddhist curriculum rather than a diluted version integrated with Western clinical approaches. Loizzos program preserves the three higher trainings of lifestyle (sila), awareness (samadhi) and outlook (prajna), in contrast to Western adaptations such as MBSR and MBCT that emphasize the awareness training branch of the system exclusively. The program also teaches advanced stages of mindfulness meditation and analytic insight, used specifically to decondition the reified self-habit. In the late 1970s and 1980s Herbert Benson made famous the completely secular relaxation response, which was followed a decade later by the Jon KabbatZinns MBSR, which combined Buddhist mindfulness with behavioral 207

medicine. Loizzos protocol, in terms of the evolution of mindfulness meditation research, has been decisive in bringing the clinical application of meditation back to its unmodified traditional Buddhist origins, and empirically investigating this reintegration. It is highly recommended that contemporary Western researchers and clinicians continue this direction of investigation and dialogue with Asian contemplatives and Buddhist scholars. Concluding Remarks Given the growing clinical interest in mindfulness meditation, the current study has attempted to provide a multiperspective review of its theory, application and effects. The study has drawn attention to the importance of respecting, acknowledging, and applying Buddhist psychology as a valid and coherent therapeutic system in its own right, rather than on extracting its essential ingredients for integration with Western approaches. The limitations of the latter activity have already been described (Loizzo & Blackhall, 1998). This study pointed out that the empirical literature on mindfulness meditation has not examined the benefits of this traditional Buddhist practice to the fullest extent. The examination of Buddhist mindfulness meditation, within its originating context in particular, drew attention to the import of deregulating the self-habit (atmagraha). The central notion of selflessness continues to be largely evaded in the Western research, except by a few scholars who appear to possess training in both Buddhist and conventional psychologies (Epstein, 2001; Loizzo, 2000; Rubin, 1996). 208

While the full potential of mindfulness to undercut egocentricity has not been understood or utilized in the Western health context, mindfulness has nevertheless been utilized effectively in medicine and psychotherapy to deregulate cognitive-affect-behavioral patterns that cause suffering. Western mindfulness research is still in its infancy and in need of greater methodological rigor, yet there is an increasing consensus regarding the empirical validity of mindfulness meditation in a diverse range of clinical contexts. Additionally, mindfulness meditation meets managed cares standard of being symptom-generalized, time-limited, cost-effective, patient-friendly and manualized as a treatment protocol, and thus holds enormous promise as a clinical intervention (Bishop, 2002; Goleman & Gurin, 1993). In the present study, the literature was found to support mindfulness meditation as a unique method with the capacity to therapeutically transform the body, brain, and mind. Current evidence supports the ability of mindfulness meditation to elicit a relaxation response that can counteract autonomic fight-flight reactivity, decrease the likelihood of stress-prone physical illnesses and improve immune functioning. Mindfulness meditation was found to activate the brains right hemisphere leading to positive-affective states, arresting the longterm degradation of neural tissue caused by allostatic load, and stimulating neural plasticity and repair. Mindfulness meditation was also found to foster metacognitive-detachment and emotional-balance, providing an integrated cognitive-affective-behavioral framework that individuals could use to help them more effectively cope with physical 209

and mental stressors and illnesses. Finally, according to Buddhist sources, mindfulness meditation could lead to a renunciation of the dissatisfying nature of compulsive and habitual living, deautomatize unhealthy outlooks, attitudes, and behaviors, and provide experiential relief by supplanting ones identification and reification of a fixed self, with the flexibility and openness of identity boundaries associated with insight into selflessness. The increased attention on mindfulness meditation in empirical research, and its utilization in clinical contexts for a wide range of healthrelated issues, made a comprehensive review of the literature on this subject both timely and significant. As future large-scale controlled clinical trials are in preparation to correct the methodological weakness of previous empirical research, the present study has tried to complement quantitative findings by filling in theoretical gaps regarding the cultural origins, traditional and conventional applications, causal mechanisms, and potential benefits and limitations of this ancient technique. In addition to documenting the growing popular interest, statistical validity and clinical use of mindfulness-based interventions, this study has attempted to draw increased attention to the Buddhist origins and utility of this sophisticated centuries-old technique. Specifically, it is proposed that clinicians and scientists, who seek to understand the mechanisms and applications of mindfulness, should engage in a systematic study of the traditional Buddhist psychological system and its meditation practices and engage in dialogue with its representatives. In this manner, it may be possible to gain greater access to the wisdom this 210

tradition possesses and the liberating effect that is its central therapeutic massage. Empirical studies in the future will be responsible for shedding light on any remaining benefits that have eluded Western research thus far.

211

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APPENDIX A: ABREVIATIONS OF BUDDHIST TEXTS Ap As Bs Dhp Dcp Jrv Kn Msp Abidhamma-pitaka Anapanasati Sutta Bahiya Sutta Dhammapadda Dhammacakkappavattana Sutta Jaravagga Sutta Kuddha Nikaya Maha-satipatthana Sutta

Mpn Maha-parinibbana Sutta Ss Sn Sp Spv Stp Stv Vp Ud Samadhi Sutta Samyuta Nikaya Satipatthana Sutta Satipatthana-vibhanga Sutta Sutta-pitaka Sutta Vibhanga Vinaya-pitaka Udhana

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APPENDIX B: GLOSSARY OF BUDDHIST TERMS Definitions by Author. Abhidharma (Sankrit) Abhidhamma (Pali): Psychological Analyses. The third part of the Buddhist Canon (tripitaka), the others being the ethical teachings (vinaya) and the discourses of the Buddha (sutra). Contains a systematic analysis of human psychology, personality and the nature of reality. Adhisiksya (Skt) also Trishiksya (Skt): Threefold Education. The three higher trainings of Buddhist education: behavioral discipline (shila), meditation (samadhi) and wisdom (prajna). Anapanasati (Pali): Mindfulness of breathing. Alertness during inhalation and exhalation. Anatman (Skt) Anatta (Pali): No-self. Absence of a permanent, unchanging, nonrelational self or soul. One of the three marks of existence (trilakshana). In the Theravada the term refers to the nonexistence of the permanent self. The illusion of a person consists of the five aggregates (skhandas) but there is no essential self. The Mahayana adds the nonsubstantiality of elements (dharmas) that constitute phenomenon. Elements exist only by means of the union of conditions. There is no eternal and unchangeable substance in them. Arhat (Skt): Worthy one. One who has completely released all fetters. The ideal or saint of the Hinayana tradition, who has eliminated both the cognitive (asrava) and emotional (klesha) defilements that obstruct personal liberation. Ariya-sacca (Pali): Four Noble Truths. The central doctrine of Buddhism. The Buddhas four phase therapeutic model of suffering including symptom (Dukkha), diagnosis (Samudaya), prognosis (Nirodha), and treatment (Ashtangika Marga). (a) Suffering exists, (b) and is caused by misknowledge, (c) there is remedy know as nirvana, and (d) the way to nirvana is an Eightfold Path that promotes morality, meditation, and wisdom. Avidya (Skt) Avijja (Pali): Delusion, misknowledge. The primary cause of suffering according to the teaching of dependent origination (pratityasamutpada). One of the three poisons (the others being attachment and aversion) that binds being to conditioned existence (samsara). In the early schools (Hinayana) represents the misperception that self or personality is separate and autonomous, and in the later schools (Mahayana, Vajrayana) 248

is understood as ignorance of the fundamental relativity (shunyata) of all phenomenon. Bhavana (Skt): Familiarization or cultivation of the mind. The term refers to meditation, an array of mental training techniques that access and develop different states of consciousness. Bodhicitta (Skt): Spirit of Enlightenment. The aspiration to achieve perfect Buddhahood for the benefit of all living beings. Bodhisattva (Skt): Enlightened hero. The ideal or saint of the Mahayana who seeks perfect enlightenment through the practice of the 10 perfect virtues (paramitas), but forgoes personal salvation until other sentient beings reach this goal. The bodhisattva is characterized by his altruistic intention/motivation (bodhicitta) as well as the wisdom of emptiness (shunyata). Buddha (Skt): The Awakened One. Any being who achieves enlightenment (nirvana) and is freed from conditioned reality (samsara). According to the Mahayana view, Buddha is the potential and essential nature for awakening that exists in all sentient beings. The Buddha of this historical age is known as Gautama Buddha or Shakyamuni Buddha, who gained enlightenment in Gaya, India, around 560 B.C.E. Buddhisodhana (Skt). Meditative self-correction. In the Mahayana, deobjectifying intuition guided by language therapy combine to create a critical method of self-correction. Chakra (Skt): Elaborate subtle body or nonphysical nervous system containing neural complexes (chakra), neural energy (prana), neural pathways (nadi), and neurotransmitters (bindu). Dharma (Skrt) Dhamma (Pali): Various meanings including the truth in regards to the nature of things; the law as related to karmic causality; the sacred teaching of the Buddha which reveal the essential qualities of suffering and salvation. Dhyana, Jhyana (Skt): Meditative absorption. Generally any absorbed state of mind that results from concentration meditation (samadhi). Specifically refers to four stages of absorption in the form realm in which the following states are subverted as ones trance progresses: sympathetic joy (mudita), loving-kindness (metta), compassion (karuna) and equanimity (upeksha). Dukkha (Skt): Dissatisfaction, suffering. Central concept in Buddhism, which lies at the root of the Four Noble Truths. The three characteristics 249

of reality (trilakshana) are that phenomena lack autonomous self-essence (anatman and shunyata) and are therefore impermanent and transitory (anitya) and are therefore dissatisfying (dukkha) and not to be relied upon. Dukkha also refers to everything that is conditioned and therefore not liberated. Guru (Skt): Spiritual teacher, mentor, guide. Kalyanamitra (Skt): Spiritual friend. May include Gurus, virtuous friends, wise persons, Bodhisattvas, Buddhas, anyone who can help the practitioner progress along the path to enlightenment. Karma (Skt): Action. Habitual action or conditioned behavioral patterns. The universal law of cause and effect. Based on causality (pratityasamutpada) an individuals volitional intention produces a specific result, which can ripen in this or a next life and which also predetermines future intentions. Karuna (Skt): Compassion. Central motivation in Mahayana Buddhism, where it is viewed as indispensable from the realization of emptiness (shunyata). Klesha (Skt) Klesas (Pali): Defilement. Addictive emotions. Maladaptive emotional responses. Mahayana (Skt): Great Vehicle. One of the three major schools of Buddhism, the other two being the Way of the Elders (Hinayana) and the Adamantine Vehicle (Vajrayana). Commonly found in Tibet, China, Japan, Korea and other East Asian Countries. Arose during the 1st-century C.E., and distinguishes it self from the early schools in a number of ways including less emphasis on monasticisms and personal salvation, and more emphasis on universal responsibility and social liberation. Characterized by its revolutionary understanding of emptiness/relativity (shunyata) it critiques and revises many of the traditional teachings and holds compassion as its central virtue. Mantra (Skt): Incantation, mental command, mnemonic spell, concentration formula. Sanskrit word meaning uniting and holding, that is, uniting all truths regarding reality (dharmas) and holding all meanings. Mudra (Skt): Hand gesture in meditation or ceremony, each representing or suggesting a specific meaning. Nirodha (Skt): Destruction. Dissolution of the cognitive and affective obstacles to enlightenment. The Third Noble Truth that proclaims the 250

possibility to be free from suffering, to enter into nirvana, specifically by eliminating the causes of future rebirth. Nirvana (Skt): Extinction. The ultimate realization in all schools of Buddhism. In early Buddhism (Hinayana) it refers to a release from cyclic conditioned existence (samsara) requiring the complete overcoming of the three poisons (ignorance, desire, and hatred), addictive emotions (klesha) and the determining effect of action (karma). Nirvana is unconditioned and is characterized by an absence of arising, subsisting, changing and passing away. In the later school (Mahayana) nirvana is seen as inseparable from conditioned reality (samsara) based on a nondual understanding developed through the insight into relativity (shunyata). Nirvana is conceived as the union of bliss and openness inherent and ever-present in all things. Prajna (Skt): Wisdom. Super knowing. Insight into the true nature of things, associated with emptiness (shunyata) and as a prerequisite for enlightenment (nirvana). The suffix jna comes from the same root as the term gnosis. Pramana (Skt): Valid cognition. Indian epistemological systems rely on refined subjective awareness as a valid means of investigating the nature of self and reality. Also known as subjective-objectivity and first-person objectivity. Pratitya-samutpada (Skt): The law of causal interdependence also known dependent origination, conditioned genesis, or interrelated causality. Central teaching of all schools of Buddhism, which accounts for the appearance of reality and the self through the mutual arising of 12 interdependent factors. Describe how reality is interrelated, and is later equated with emptiness (shunyata), as phenomenon possesses no autonomous or intrinsic essence. Rupa (Skt): Body, material form, or the five elements of physical reality. Sadhana (Skt): An esoteric or Tantric meditation practice involving rituals, visualization, invocation, and recitation of mantras. Samadhi (Skt): Nondual absorption. The culmination of the Path of Concentrative in an ecstatic experience of union with the meditative object. Samadhi dissolves subject-object dualism, but remains a conditioned state from which one must return to the state of the desire realm (kamloka).

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Samsara (Skt): Refers to cyclic existence from one rebirth to the next in a state of suffering and dissatisfaction (dukkha), propelled by delusion, attachment and aversion. Conditioned or unenlightened existence. The type of rebirth in samsara is determined by action (karma) and can be liberated from through the realization of shunyata and nirvana. Samskara (Skt) Sankara (Pali): Mental tendency, mental formation, or mental construction. Generally referring to the way thought patterns and constructs are formed and fashioned. One of the five aggregates (skhandas) of personhood. Sati (Pali) Smirti (Skt): Mindfulness, alertness, attentiveness, remembering. Satipattana (Pali): Meditation technique developed by the Buddha and unique to Buddhism, which calls for an even flowing nonjudgmental attention of the body, feelings, mind states, and thoughts of the present moment. Is said to be the necessary method that leads to enlightenment. Satipatthana Sutta (Pali): Famous meditation text on the four foundations of mindfulness also translated as the four frames of reference, found in Digha Nikaya, the Long Discourses of the Buddha. Shamata (Skt) Samatha (Pali): Tranquility. Concentration meditation technique that focuses awareness on one specific subject, often inducing trance-like states (dhyana), calmness and equanimity, and culminating in absorption (samadhi). The common feature of all meditation systems developed throughout the world. Shila (Skt) Sila (Pali): Morality, behavioral discipline. Refers to the ethical guidelines set down for the moral conduct of monks and nuns. Is the foundation of the three higher trainings (trishiksha), in which ethical conduct serves to stabilize the mind and prepare it for intellectual and meditative learning. Shunyata (Skt): Voidness, Emptiness. The central notion of the Mahayana that revolutionized Buddhist thought and practice, proposed most eloquently by the scholar sage Nagarjuna. The concept goes a step beyond the limited meaning of no-self (anatman), to imply a lack of absolute essence and autonomy in all phenomena. It is because of this lack of essentiality that all things can relate, and therefore has been equated with the notion of relativity. Skandas (Skt) Kandhas (Pali): Aggregates. Term for the five systems that constitute what is generally known as personality. They are (a) material form (rupa), (b) sensation (vedana), (c) perception (samjna), (d) mental 252

formations (samskara), (e) consciousness (vijnana). The characteristics of the skandhas are birth, old age, death, duration and change. They are regarded as without intrinsic essence (anatman), are relational (shunyata), impermanent (anitya) and dissatisfactory (dukkha). Smirti (Skt): See Sati. Sukkha (Skt): Bliss, joy, happiness or peace. A state of mind cultivate through concentration meditation (shamata). Experienced as one of the divine abodes (brahma vihara) of the form realm (rupaloka). Sutra (Skrt) Sutta (Pali): Formula, sermon, teaching, discourse, text or scripture. Stupa (Skt): Reliquary. Typically dome shaped, burial mounds containing relics of the Buddha or other enlightened beings that serve as places of veneration, ceremony and pilgrimage. Tantra (Skt): Sacred text or methods containing esoteric knowledge and practices. Tatagatha-garba (Skt): The embryo of enlightened potential. The innate Buddha-nature present in all beings obscured by defilements. Theravada (Skt): The Way of the Elders. The last surviving of the original 18 Hinayana schools that preserved the classical Pali Canon (tripitaka). Represents the original Buddhist movement developed in the first 5 hundred years after the Buddhas death. Commonly found in Thailand, Sri Lanka, Burma and Cambodia. Holds renunciation as it primary virtue, the arhant as it ideal and strives for individual liberation. Trilakshana (Skt): Three marks of existence: impermance, selflessness and dissatisfaction. Reality is said to be impermanent (annicca) because it lacks enduring essence (anatman) and is therefore unreliable and produces suffering (dukkha). Trilokas (Skt): Three realms of consciousness: desire realm (kamaloka) of ordinary suffering, the form realm (rupaloka) of sublime states (brahma vihara) and positive emotions, and the formless realm (arupaloka) of meditative absorption. Tri-Pitaka: Three baskets or collections of the Pali Canon consisting of the Vinaya Pitaka (scriptures on discipline), the Sutta Pitaka (scripture of the Buddhas sermons), and the Abhidhamma Pitaka (scriptures on Buddhist psychology). 253

Trishiksha (Skt) also Adhishiksha (Skt): Threefold Education. The three higher trainings of Buddhist education consisting of moral ethics and behavioral discipline (shila), meditative skill and attentional control (samadhi) and wisdom and experiential insight (prajna). Upaya (Skt): Expedient technique, skillful means. Refers to strategies, methods, devices targeted to the capacities, circumstances, likes and dislikes of each sentient being, so as to effectivly lead them to enlightenment. Upadana (Skt): Compulsive behaviors. Attachment to the five aggregates of being (skandhas) that leads to suffering. Vajrayana (Skt): Adamantine or Apocalyptic Vehicle. One of the three main divisions of Buddhism, which arose in north India around the middle of the first millennium. It was transported to many of the same countries as the Mahayana including parts of East Asia but is practiced predominantly in Tibet, Mongolia, Bhutan and Sikkim. It incorporates both monastic and social forms of practice, but is distinguished by the inclusion of esoteric, highly developed ritual practices known as Tantra. Vedana (Skt): Feeling. Any sensation falling between the extremes of pleasure (ease) and pain (stress) including neural sensations or absence of feeling. Vichara (Skt): Evaluation. Scanning awareness. In meditation, vicara is the mental factor that allows one's attention to shift, scan and move about in relation to the chosen meditation object. It is closely related to direct thought (vitarka). Vijnana (Skt) Vinnana (Pali): Consciousness, cognizance. The act of taking note of sense data and ideas as they occur. One of the five aggregates (skandhas) that constitute the illusion of personhood. Vinaya (Skt): The precepts for monks and nuns, designed to help them eliminate defilements. Vinaya Pitaka refers to the body of ethical rules and disciplines for Buddhist monks and laypersons prescribed by the Buddha. One of the three collections contained in the Buddhist Pali Canon (Tripitaka), the other two being the Buddhas discourses (sutras) and psychological commentaries (abhidharma). Vipassana (Pali) Vipashyana (Skt): Insight, clear seeing. In the Hinayana refers to the intuitive realization of the three marks of existence (trilakshana), while in the Mahayana refers to an examination of the nature of things leading to insight into emptiness (shunyata). A meditative 254

technique that incorporates calm-abiding or concentration practice (shamata/samadhi) with mindfulness (satipattana) and discursive analysis. Develops the necessary skill for cognitive/affective relearning and is the prerequisites for awakening (bodhi). Vitarka (Skt): Directed thought, concentrated attention. In meditation, vitarka is the mental factor by which one's attention is applied to the chosen meditation object. Closely related to evaluation (vichara). Yanas (Skt): Vehicles. Metaphor for the Buddhas teaching that carries all living beings to enlightenment and liberation. There are three vehicles, the Lesser Vehicle (Hinayana, Theravada) designed for individual liberation, the Greater Vehicle (Mahayana) designed for social liberation and the Adamantine Vehicle (Vajrayana, Tantrayana) designed for expedient liberation of individual and collective simultaneously. Sometimes there is mention of only Two Vehicles, one for the Sravakas and Pratyekabuddhas who aspire for solitary enlightenment and a second for Bodhisattvas and Buddhas who completely realize ultimate reality.

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