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Empathy, Psychotherapy Integration, and Meditation: A Buddhist Contribution to the Common Factors Movement
David T. Andersen Journal of Humanistic Psychology 2005 45: 483 DOI: 10.1177/0022167805280264 The online version of this article can be found at: http://jhp.sagepub.com/content/45/4/483

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Empathy, 10.1177/0022167805280264 David T. Andersen Psychotherapy Integration, and Meditation

EMPATHY, PSYCHOTHERAPY INTEGRATION, AND MEDITATION: A BUDDHIST CONTRIBUTION TO THE COMMON FACTORS MOVEMENT
DAVID T. ANDERSEN, Ph.D., has practiced meditation in the Buddhist tradition (first vipassana and then Zen) for 35 years. He earned an Ed.M. from Harvard University and a doctorate in clinical psychology from the Derner Institute at Adelphi University. He is presently a school psychologist in Norwalk, Connecticut, and an adjunct professor in the Psychology and Education Departments at Sacred Heart University. He is also a licensed clinical psychologist with a private practice in Stamford, Connecticut. Clinicians from several theoretical approaches have explored the c ommon g r ou n d betw een Bu ddh ism an d Wester n psychotherapeutic models. In this article, the synthesis of Buddhism and psychotherapy is considered from the context of psychotherapy integration. Toward that end, the Buddhism and psychotherapy literature and the psychotherapy outcome research is reviewed with a focus on the findings of therapy equivalence and common factors among treatment approaches. Empathy and the relationship variables factor are discussed; it is argued that Buddhist meditation contains a dialectic between striving and self-acceptance. An essential aspect of meditation is seen as identical to an essential component in therapeutic personality change. It is argued that therapist empathy and meditation promote a self-directed empathy that enhances the interdependence, integration, and cohesion of self. Several approaches to the integration of psychotherapy and Buddhist meditation are compared to the views presented here, and recommendations are offered for the clinical application of meditation training.
AUTHORS NOTE: Please address requests for reprints of this article to David T. Andersen, Ph.D., 83 Morgan St., Apt. 5-C, Stamford, CT 06905; e-mail: david7354@ SBCglobal.net.
Journal of Humanistic Psychology, Vol. 45 No. 4, Fall 2005 DOI: 10.1177/0022167805280264 2005 Sage Publications 483-502

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Keywords: empathy; psychotherapy integration; meditation

To study Buddhism is to study the self. To study the self is to forget the self. To forget the self is to be enlightened by all things. To be enlightened by all things is to remove the barriers between oneself and others.
Zen Master Dogen [1200-1253 C.E.] (1976), p. 39

Even a casual reader of Buddhist literature might recognize that a recurring theme in Western Buddhism has been the integration of psychotherapy and Buddhist practice. Clinicians from diverse therapeutic approaches have described (in books, magazines, and professional journals) their integration of insights, concepts, and techniques from Buddhist meditation into their theory and practice of psychotherapy (Brazier, 1995; Epstein, 1995, 1998; Linehan, 1993; Magid, 2002; Rubin, 1996). Although each of these integrations should be judged in its own context and on its own merits, another way to understand and evaluate this trend, and another way to make use of it, is to view the synthesis of meditation and psychotherapy within a larger perspective. There is currently a movement within mainstream clinical practice toward psychotherapy integration. A growing number of psychologists have combined or synthesized concepts and methods from one or more therapeutic models to generate new theories and more effective models of intervention (Stricker & Gold, 1996). Motivated by practical concerns (the need to empirically justify insurance coverage for therapy) and the findings from the decadeslong history of psychotherapy outcome research, psychologists working in the field of psychotherapy integration have looked for evidence for the effectiveness of psychotherapy and have sought to identify commonalities among therapeutic approaches. In addition, psychotherapy integrationists have addressed questions that have been raised, from research findings and clinical experience, about how therapy actually affects psychological change. Although it is likely that most clinicians who practice meditation would not suggest that the two disciplines are interchangeable, it may be that meditation has something to contribute to the discussion of

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what makes therapy work. In this article, I review the literature on the integration of Buddhism and psychotherapy and the findings from research on psychotherapy outcome. In addition, I argue that an essential aspect of meditation is identical to an essential component in therapeutic personality change. More specifically, I maintain that therapist empathy and Buddhist meditation promote a self-directed empathy that enhances the interdependence, integration, and cohesion of self. Finally, I compare my view of meditation and psychotherapy with views expressed in the literature and provide a rationale for the use of meditation in clinical training.

BUDDHISM AND PSYCHOTHERAPY The movement to compare, contrast, and, ultimately, to integrate concepts and techniques from the Buddhist practice of meditation into Western psychotherapeutic models has a long history. Freud (1930) originally broached this subject when contacted by the French Nobel Laureate Romain Rolland about the usefulness of meditation. Referring to Rollands oceanic experience while the poet had studied with a well-known meditation teacher in India, Freud dismissed meditation, viewing it as a primitive defense and a regression to an infantile narcissism. Other psychoanalytic writers agreed with Freuds pessimistic and reductionistic view of meditation, arguing that meditation is best understood as an artificial schizophrenia (Alexander, 1931) or as an expression of narcissistic megalomania (Masson & Hanly, 1976). A notable exception to this negative perception of meditation was offered by Eric Fromm. In Zen Buddhism and Psychoanalysis (Fromm, Suzuki, & DeMartino, 1960), Fromm argued that Zen and psychoanalysis have much in common, including an abiding distrust in conscious thought and a belief that self-knowledge leads to self-transformation. Fromm also suggested that Zen practice may actually be better equipped than Western psychotherapeutic approaches in helping people more effectively manage the modern problems of emptiness and self-alienation. In an article that makes an early connection between empathy and meditation, Schuster (1979) argued that the choiceless awareness characteristic of mindfulness meditation and the Zen practice

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of shikan-taza (just sitting) is likely to enhance the capacity for empathy. Schuster suggested that meditation practice would help therapists adopt an open and nonjudgmental awareness, making it possible for an intuitive, direct, and authentic grasp of the clients experience. Clinicians examining the relationship between meditation and psychotherapy have focused on the question of meditation and ego development. Wilber (1993) has suggested a sequential use of medi t a t i o n a n d p sy ch o t h e ra p y, a rg u i n g t h a t e g o - f o cuse d psychotherapies address a level of awareness where meditation is not a relevant intervention. In similar arguments, Wellwood (1983) and Engler (1993) have suggested that there are different goals for therapy and meditation: The former addresses the need to develop a strong ego whereas the latter is concerned only with issues of transcendence. Meditation from this perspective (ego development) would be contraindicated for persons struggling with poorly developed internal representations of self and other or for those who have difficulty maintaining the integrity and coherency of self. Engler (1993) captured the essence of this position with his oft-quoted statement You have to be somebody before you can be nobody (p. 119). In contrast to the view that meditation and psychotherapy address different levels of development, Epstein (1995, 1998) has cogently argued against the notion that meditation is only appropriate for persons with a fully developed personality. Epstein pointed out that not only would this criterion place meditation beyond the reach of most people but also that the capacity for the ego to maintain its strength and integrity is enhanced by the mindfulness aspect of meditation. When the contrasting experiences of delight and terror are held within a mindful attention, meditators learn to accept, tolerate, and contain fantasies of omnipotence while they viscerally experience the essential impermanence of a separate self. Moreover, Epstein (1995, 1998) suggested that mindfulness meditation may have a part to play in the remediation of deficits in the development of a healthy sense of self. Referring to Winnicots notion of a false self and Balints concept of an implicit experience of a basic fault, Epstein (1995) argued that mindfulness meditation helps patients deconstruct and then relinquish the pathology caused by faulty relationships (intrusive or indifferent) with primary caregivers. Writing from a self-psychological perspective, Magid (2002) seemed to agree, suggesting that the day-

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to-day practice of meditation, even when not accompanied by participation in extended retreats, promotes the development of internal structures that provide the capacity to more fully tolerate, contain, and organize emotional experience. In a thoughtful and comprehensive restatement of his ideas, Engler (2003) acknowledged and agreed with the criticism of his developmental model of psychotherapy and meditation. Engler noted that his therapy-first approach emerged primarily from his work with patients who were drawn to the Buddhist concept of anatta (a core Buddhist tenet that denies the existence of a separate self) as a way to bolster narcissistic defenses, avoid personal responsibility, rationalize fears of intimacy, or otherwise maintain distance from unwanted affect. In addition, Engler acknowledged that meditation, indeed, enhances the development of ego strengths, most notably the capacity for affect tolerance and selfobservation. Engler also agreed with his critics (Epstein, 1995; Kornfield, 1993) that meditation practice should not be seen as discontinuous with the development of a healthy sense of self and a greater capacity for intimacy. Finally, Engler argued that meditation and psychodynamic psychotherapy produce therapeutic effects in a sequential process, first by changing cognition through insight, then affect, and ultimately, the core sense of selfhood. Working primarily from a behavioral perspective, Linehans (1993) integration of Buddhism and psychotherapy focused on the capacity for meditation to regulate emotional experience. Linehans dialectical behavior therapy (DBT), an empirically based approach to the treatment of borderline personality disorder (BPD), is based on dialectical theory, a philosophical position consistent with Buddhist philosophy in its emphasis on process and change and the inherent interdependence of all phenomena. Linehan saw BPD as a dialectic failure; that is, the extreme thinking and emotional dysregulation characteristic of BPD denote a failure to achieve a synthesis of dichotomous and opposing internal forces. For patients diagnosed with BPD, Linehan used meditational techniques to help regulate emotional experience so that the fundamental dialectical failure of this disorder, the inability to implement strategies for behavioral change in the context of self-acceptance, can be brought to a successful and adaptive synthesis. Writing from a psychoanalytic perspective, Rubin (1996, 2003) looked at the synergistic effects of meditation and noted that inte-

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gration should be a reciprocal process. Citing the scandals of the past two decades involving the abuse of power at Buddhist centers and his own clinical experience in working with patients who meditate, Rubin argued that meditation practice, by itself, is sometimes insufficient in uncovering and then working through archaic transference phenomena. Rubin suggested that meditation and psychoanalysis convey different and incomplete epistemologies of self. Whereas meditation focuses on the here and now, existential, atheoretical, and dereified perceptions of experience, psychoanalytic theory examines the ways in which personal history distorts or confuses the experience of self, other, and even the experience of Buddhist practice itself. It is Rubins point that combining the two approaches might help strengthen the weaknesses in both. In a research design that is likely to become an important trend in the integration of Buddhism and psychotherapy, Schwartz (Schwartz & Begley, 2002) used the tools of neuroscience to support his integration of cognitive therapy and mindfulness meditation. Recognizing that the neural pathways associated with obsessivecompulsive disorder (OCD) result in the perseveration of error messages in the orbital frontal cortex, Schwartz developed a treatment that integrates the reframing of these error messages with the techniques of mindfulness meditation. When dropout rates are taken into account, Schwartzs treatment has been shown to be more effective, and is likely more humane, than the behavioral techniques of exposure and flooding most frequently used for this disorder. Moreover, Schwartz has demonstrated that meditation and psychotherapy produce neuroplasticity, the capacity for the structure and functioning of the brain to be shaped by experience. Finally, Teasdale and his colleagues (Segal, Teasdale, & Williams, 2001) demonstrated that meditation, when combined with cognitive therapy, can significantly reduce the rate of relapse for patients experiencing multiple (three or more) episodes of depression. In Teasdales approach, mindfulness meditation helps patients experience problematic thoughts as simple mental events that do not necessarily reflect accurate interpretations of experience. Moreover, this implicit reframing (in meditation) of problematic cognition allows for the activation of competing thoughts that provide rational, adaptive, and healthy responses (in the form of counterarguments) to the depressogenic cognitive patterns characteristic of major depressive disorder.

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In summary, the literature on meditation and psychotherapy includes the integration of meditation with cognitive, behavioral, and psychodynamic therapeutic approaches. Meditation is viewed as helping patients repair deficits in the development of selfstructures, increase insight into repetitive patterns of internal conflicts, expand the capacity for affect regulation, and increase the ability to identify and then correct maladaptive cognition. Although Schuster (1979) made a connection between empathy and meditation (a primary concern of this article), he concentrated on the effects of meditation on therapist empathy. In this article, I expand the discussion of empathy, psychotherapy, and meditation by focusing on the integrative function of empathy and argue that therapy and meditation effect psychological change by enhancing the capacity for self-directed empathy. In the following section, I review the research on therapy outcome, emphasizing the findings of outcome equivalence and the common factors among therapeutic approaches. In addition, I argue for the importance of empathy in therapeutic personality change.

RESEARCH ON PSYCHOTHERAPY OUTCOME Over several decades, Hans Eysenck (1952, 1993) maintained that there was no credible evidence that psychotherapy actually helps people who struggle with mental health concerns. Eysenck argued that in spite of the implicit belief among clinicians in the effectiveness of psychotherapy, the research on therapy outcome was inconclusive; many studies showing the effectiveness of psychotherapy were poorly designed or the results did not demonstrate that psychotherapy is more effective than placebo treatments. More recently, insurance companies, who have assumed payments for the provision of clinical services, have required that psychologists provide empirical data demonstrating the effectiveness of psychotherapeutic treatment. Findings from several well-controlled studies on psychotherapy outcome and from a succession of meta-analytic evaluations consistently demonstrate that psychotherapy is an effective treatment for people with mental health concerns (Weinberger, 2002). In addition, this research demonstrates that no therapeutic approach is better than any other in affecting psychological

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change. These findings are widely referred to as the Dodo bird verdict in which Everyone has won and all must have prizes (Rosenzweig, 1936, p. 412). The evidence for therapy outcome equivalence strongly suggests that the factors alleged to be working by each model are not the actual or only factors causing psychological change (Weinberger, 2002). Indeed, researchers have identified five common or nonspecific factors that account for the variance in the dependent measures used in therapy outcome studies. These factors are relationship variables, expectancies, confronting problems, mastery, and the attribution of outcomes (Weinberger, 2002). Of these five nonspecific conditions of treatment, the strongest predictor of successful outcome has been, indisputably, the relationship variables factor (Luborsky, Crits-Christoph, Mintz, & Auerbach, 1988; Orlinsky & Howard, 1986; Stubbs & Bozarth, 1994). Although the therapeutic relationship includes several dimensions, its central component remains true to the classic Rogerian theory of the necessary and sufficient conditions for successful treatment (Bozarth, 1997). Rogers (1957) identified three core conditions of successful psychotherapy: therapist empathy, unconditional positive regard, and genuineness. Bozarth asserted that these three conditions are seamlessly connected because the capacity for empathy is essential to the therapists attitude of unconditional positive regard toward the client and to the therapists ability to be genuine or congruent in the therapeutic relationship. Although many researchers have criticized or dismissed the core conditions in Rogerian theory as conceptually inadequate or as neither necessary nor sufficient conditions for successful treatment (Gelso & Carter, 1985; Luborsky, Singer, & Luborsky, 1975; A. K. Shapiro, 1971), Bozarth, Zimring, and Tausch (2002) argued that this dismissal has not been empirically based. Although the initial rejection of Rogerian theory was based only on a methodological critique of a small number of studies, not one study has been published supporting the assertion that the core conditions are not sufficient. More important, in Bozarths (Bozarth et al., 2002) review of five decades of research on therapy outcome, he noted that the therapist-client relationship, combined with the clients resources, have been shown to account for 30% to 40% of the variance in successful treatment. In addition, Bozarth

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and his colleagues found that the conditions of empathy, unconditional positive regard, and congruence are the therapist variables most often associated with successful treatment. Finally, psychologists have suggested that the qualities of attention characteristic of a mindful awareness constitute a common factor in successful psychotherapy (Martin, 1997). Horowitz (2002) defined mindfulness by combining concepts derived from Buddhist philosophy and the literature of social psychology. Horowitz viewed mindfulness as a flexible awareness that is centered primarily on those feelings, thoughts, and sensations that are occurring in the present moment. Mindfulness is also characterized by a compassionate understanding of others that leads to a greater capacity for self-observation. As I demonstrate in the following discussion of empathy in clinical practice, this definition of mindfulness is consistent with the view of empathy in the humanisticexperiential approaches to psychotherapy. EMPATHY IN CLINICAL PRACTICE In clinical practice, the self-psychological and humanisticexperiential approaches have generated the most interest, theoretical and empirical, in the influence of empathy on the therapeutic process. Self-psychologists view empathy as a process of vicarious introspection where the empathic responses of therapists are guided by their ability to imagine what it would be like to have the patients experience. In their identification with the patient, therapists introspect, or pay attention to, what they imagine the patient would be feeling (Kohut, 1984). In this model, empathy is a tool that the analyst employs to generate experience near (and therefore more accurate) clinical information. Although vicarious introspection does not include the communication of emotional experience, patients are likely to feel accepted by the therapist because the logic of their internal frame of reference is not challenged or submitted to objective standards of reality testing (B. Magid, personal communication, October 7, 2002). In contrast, empathy in humanistic and experiential approaches is cast in cognitive and affective terms (Bohart & Greenberg, 1997). In their review of empathy in humanisticexperiential psychotherapies, Bohart and Greenberg (1997) noted

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that empathy has been defined as the nonjudgmental understanding of the clients immediate frame of reference that helps the client to become more compassionate and empathic toward the self. The communication of therapist empathy helps clients replace negative evaluations of self with the capacity to accept and integrate previously disowned experience. In addition, in some humanistic-experiential approaches empathy is seen as necessary to the construction of the therapeutic alliance and the repair of damaged patterns of experiencing. I would also argue that the combination of affect and cognition provides empathy with an existential or ontological base; that is, the understanding and acceptance of the client proceeds from and deepens the therapists ability to simply be with and stay with experiences as they arise in the therapeutic hour. To summarize, an important difference between empathy in the self-psychological and humanistic-experiential traditions seems to turn on the concept of acceptance. In self-psychology, empathy is primarily a cognitive process that does not normally include an affective component. If the patient feels accepted by the analyst, it is because the analyst has not attempted to contradict the patients version of events. In contrast, in humanistic-experiential traditions therapist empathy is defined as the nonjudgmental understanding of the clients immediate experience that helps the client recognize, accept, and integrate disavowed aspects of self. Although acceptance and empathy are not viewed as synonymous, acceptance is implied in the definition of empathy and in the way that empathy is understood to function. Although research has consistently shown a significant connection between therapist empathy and successful outcome (Bohart & Greenberg, 1997), the reason that empathy and the larger construct of relationship variables are associated with successful treatment has not been demonstrated empirically (Wienberger, 2002). Because there is evidence that Buddhist meditation enhances the capacity for empathy (S. L. Shapiro, Schwartz, & Bonner, 1998), and because, for Buddhists, meditation has been used for centuries as a direct route to the ending of suffering, it is reasonable to suggest that meditation may have something in common with, and something to contribute to, the experience of therapeutic personality change.

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EMPATHY IN MEDITATION: EMPATHY IN PSYCHOTHERAPY In Buddhism, particularly but not exclusively in Zen (Magid, 2002; Watts, 1957), there is an ongoing dialectic between the need to make effort in meditation and the need to sit in meditation without effort. Lacking the motivation to sit, the will to endure uncomfortable feelings, and the uncomplicated desire for meditation to make things better, it is not likely that a person will begin and then maintain a meaningful meditation practice. Yet it is also true that effort in meditation perpetuates a conflicted and dualistic experience of self. The desire to transcend experience or to change it in any way is based on the dualistic assumptions (which may, at times, be implicit) that the self is acceptable only in parts or that enlightenment exists somewhere else separate from where and who you are in the present moment. Even when meditation has moved beyond the counting of breaths and the labeling of thoughts, the dialectic continues as the meditator attempts to be present to the flow of moment-to-moment experience. For those thoughts, feelings, and sensations that are acceptable, the distance or the division between the observer of experience and experience itself may diminish until the actual interdependence and nonseparation of the two become plain. However, for those thoughts and feelings that are not acceptable, a number of defenses are used to distort or deny the self s connection to (and ownership of) experience. These defenses include the strategies of denial, displacement, rationalization, dissociation, projection, and the isolation of affect. However, what is the antidote to defensive strategies when they are employed? How is the attachment to the gap between the observer and the observed undone? I would argue that in psychotherapy, the antidote to a fragmented self begins with the experience of empathy. When patients are understood and accepted, this capacity for cognitive and affective attunement is internalized by the patient and then directed toward the self, toward those thoughts and feelings that have been, in one way or the other, avoided or disowned. Writing from a relational therapeutic perspective, Jordan (1997) suggested that therapist empathy helps patients adopt an empathic attitude toward their own thoughts

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and feelings that then allows for the reintegration of split-off experiences. Barrett-Leonard (1997) also saw self-directed empathy as a central component in effective psychotherapy. Barrett-Leonard wrote that
the impact of recognizing and accurately articulating the message of signals from a deep, precognitive level of inner being seems to radiate through the whole person-organism. At that moment the dual self is one, there is a peak of integration. It is a unity not of structure but of immediate process of inner connection and communication. (p. 109)

In addition to its integrative functions when it is internalized, therapist empathy also mobilizes the patients internal resources and faculties for development. Magid (2002) suggested that one way that therapist empathy affects psychological change is by reconnecting patients to an inner line of development that promotes the strength and cohesion of the self. Whereas selfpsychologists refer to this as the use of self-objects in the development of a cohesive self, humanistic psychologists understand this process in terms of an underlying tendency toward selfactualization. In meditation, I would also argue that the antidote to disowned or fragmented experience begins with self-directed empathy. However, the self-directed empathy in meditation is not internalized from relationships as much as it is born out of the capacity for compassion in the midst of impossible suffering; that is, when every defense is seen as a dead-end street and when the meditator recognizes the impossibility of disowning, repairing, or even transcending unwanted thoughts and feelings, effort in meditation ends and empathy begins. When the self, with all of its strengths, flaws, damage, and disorganization is understood and accepted, the need to maintain distance from disowned experiences is replaced by the direct awareness of the ontological reality of interdependence and nonseparation. To state it another way, as awareness deepens in meditation, it becomes clear that the separation from experience is held in place by anxiety and fear. In turn, the separation from experience diminishes (and ultimately is relinquished) when the effort to get rid of anxiety and fear is replaced by the compassionate acceptance of the self, just as it is.

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MEDITATION AS MATURE DEVELOPMENT It should be noted that meditation as choiceless awareness stands in sharp contrast to Freuds view of religious or transcendent experience. Whereas Freud (1930) viewed meditation as a regression to a primitive narcissism brought on by feelings of vulnerability and helplessness, the nondualistic experience in Zen practice is seen here as an expression of developmental maturity (Magid, 2002). More specifically, from the Zen perspective nonseparation occurs in the midst of the self s cohesion and strength and not as a result of the egos vulnerability to anxiety and disintegration. Furthermore, the perception that meditation is a regression to an undifferentiated narcissism is not consistent with the theory and actual practice of meditation in the Buddhist tradition. In Zen, meditation works to increase the capacity to be with and stay with experience so that affect, even when it is precognitive and implicit, becomes an increasingly differentiated experience. In other words, before the interdependence or nonseparation between the observer and the observed can be experienced, feelings and the thoughts that people have about feelings are attended to, recognized, and then more accurately represented in awareness. It should be underscored that meditation as selfdirected empathy, in that it is a combination of understanding and acceptance, plays an essential role in each aspect of this process. There has been preliminary empirical support for meditation increasing the capacity to accurately recognize the emergence of emotional experience. In a series of investigations generated, in part, from an ongoing dialogue between Western scientists and the Dalai Lama, Goleman (2003) reported initial findings from studies conducted by Paul Ekman, a researcher on the facial expression of emotion. In previous studies, Ekman (2001; Matsumoto et al., 2000) found that even when people attempt to conceal their feelings, there are still quick and fleeting microexpressions of emotions that can be reliably detected in facial expressions. These microexpressions of emotion occur prior to the conscious control of the person having the emotion and happen so quickly that they are frequently misidentified or not perceived by others. When Ekman presented two Western Buddhist monks (both accomplished meditators and recent participants in multiple year-long meditation retreats) with a video used in his research design, the monks

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accurately identified microexpressions of emotion at a level two standard deviations higher than the score previously rated as the most accurate. Moreover, the monks scored significantly higher than any other group taking this test, including lawyers, police officers, customs agents, psychiatrists, and secret service agents (the group previously identified as the most skilled in this task). If meditation does indeed increase the capacity for empathy, and if the recognition of emotional experience is an essential aspect of self-directed and interpersonal empathy, Ekmans research suggests that meditation practice might be useful in the training of clinical psychologists.

THE PARADOXICAL EFFECTS OF EMPATHY AND SELF-ACCEPTANCE It may be somewhat surprising that, paradoxically, the acceptance or nonseparation from fragmentation and disorder has the effect of transforming the self, making it resilient, cohesive, and capable of participating fully in the intersubjective reality of relationships. However, the paradoxical or ironic effects of anxiety are actually quite common to clinical practice. Wachtel (1993) noted that anxietyand the behaviors that it generatesfrequently bring about the very thing that a person wishes to avoid. For example, making an effort to sleep frequently keeps one awake, and repetitively washing hands to avoid germs often causes infections. Conversely, the relinquishing of anxiety characteristic of selfacceptance and the nonseparation from experience changes the relationship between the self and its problems, conflicts, and fears. The paradoxical effects of self-directed empathy are also consistent with ideas that have been essential to the development of the family systems approach to clinical practice. In The Cybernetics of Self : A Theory of Alcoholism, one of the first papers to connect systems theory to clinical issues, Bateson (1972) argued that the fundamental epistemological flaw of Occidental civilization turns on the underlying separation between subject and object; for alcoholics in 12-step programs, Bateson maintained that this disjunction is dissolved in a process that I would suggest is similar to the concept of self-directed empathy. When the alcoholic embraces the first two steps of Alcoholics Anonymous (which require the accurate and direct recognition of the condition of alco-

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holism and the utter futility of individual effort in bringing about an end to this condition), the problematic epistemology of dualism is changed into an experience of interdependence and nonseparation. In other words, in the systems theory of selfregulation, the compassionate acceptance of self, just as it is . . . in the very condition of alcohol dependence . . . brings about a change in that dependence. EMPATHY, MEDITATION, AND PSYCHOTHERAPY Finally, I would argue that empathy and meditation have several common features, including a remarkable similarity in how the development of these two processes are described. Although empathy in therapy is communicated interpersonally and meditation is, for the most part, an intrapersonal process, the development of empathy seems to run a parallel course to the development of Buddhist meditation. Without intending to make a connection among empathy, meditation, and psychotherapy, Gendlin (1974) nevertheless provided one. In instructions given to novice therapists on how to have empathy in therapy, Gendlin wrote,
These days we introduce listening on a experiential base. We do not first give therapists the puzzling instructions to repeat what their clients say. Rather we convey what it is like to get into yourself, to accord yourself a friendly hearing, to allow, without rebutting, the coming up of anything that will be there inwardly. We convey that in relationship to oneself, one must not immediately argue with what comes, or put oneself down for it, or explain it; rather one must gently allow it to be there, just exactly in what ever way it comes up to be felt. When this attitude is understood, listening is presented as how one would help people take that attitude toward themselves, within themselves. (p. 220)

As a Buddhist reader would note, Gendlins (1974) instructions on empathic listening given to beginning therapists are practically identical to instructions normally given to novice meditators. In addition, Gendlin seems to argue that interpersonal empathy emerges from self-directed empathy, which would then suggest that the capacity for empathy might be enhanced by meditation. Although there have been some data to support this view (Lesh, 1970; S. L. Shapiro et al., 1998), so far the research has not been consistent (Pearl & Carlozzi, 1994). For psychologists looking to

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more accurately identify the causes of successful psychotherapy, and for researchers interested in the transformative effects of Buddhist meditation, further investigation of the relationship between meditation and empathy would seem to be warranted. CONCLUSION In summary, in this article, meditation and psychotherapy are viewed as enhancing the capacity for self-directed empathy. It is also suggested that the experience of self-directed empathy is important to constructive personality change, and it may contribute significantly to the relationship between therapist empathy and successful psychotherapy. In addition, it is my view that meditation is best understood as a resolved dialectic between striving and self-acceptance where the synthesis of these opposing forces results in the integration (or interdependence) of self with disowned or fragmented experience. I should also note that unlike Linehans (1993) therapeutic approach, where dialectal tension exists between the need for selfacceptance and the behavioral strategies (including meditation) that promote emotional regulation, the view expressed here focuses on the tension between change and self-acceptance that exists within the practice of meditation. Moreover, meditation as self-directed empathy differs from Schwartz and Begley (2002) and Teasdales (Segal et al., 2001) integration of mindfulness meditation with cognitive therapy and from Englers (2003) model of therapeutic personality change. In contrast to the view in the cognitive model of mental health that inaccurate thoughts and beliefs cause maladaptive affective states and that the correction of these inaccurate perceptions leads to successful therapeutic outcomes, the view here is that emotions often drive the cognitive process and that negative thoughts attach to destructive emotions. In a view of emotion that is consistent with the central role given to affect in humanistic psychology (Greenberg, 2002), I suggest that the selfdirected empathy generated in meditation and psychotherapy influences cognition through the integration of affect. The primacy of affect in mental health concerns also suggests a rearranging of Englers (2003) schematic of therapeutic change. Whereas Engler argued that therapy and meditation have a cura-

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tive effect by first changing cognition (through insight), then affect, and then self-knowledge, I argue that the change process in meditation takes a different course, beginning with affect, then self-experience, and then cognition. Charlotte Joko Beck, an elderly, austere, and well-respected meditation teacher, refers to this as the subject-object problem in Zen (Beck & Smith, 1993). Beck suggested that meditation has its most profound affect, not when problematic thoughts are recognized and then disengaged from (as attention returns to some other object) but rather when underlying feelings are experienced without separation or rejection. Indeed, it is a common occurrence in meditation that ruminating or repetitive thoughts cease and the mind becomes effortlessly alert, quiet, and integrated when underlying feelings are directly acknowledged, understood, and accepted. And finally, if research continues to demonstrate that meditation enhances the capacity for empathy and that therapist empathy is associated with successful psychotherapy, psychologists would do well to integrate research findings with their clinical training. Noting that there are courses that teach meditation without religious affiliation, it would make sense for therapists to consider training in mindfulness techniques. Moreover, graduate programs might offer meditation training for doctoral candidates in clinical psychology, perhaps as an elective course of study. In addition to increasing the capacity for empathy, there is a large body of research (Benson, 1975; Benson et al., 1982; Davidson et al., 2003) demonstrating the ability for meditation to reduce stress and to significantly improve emotional resiliency. For example, in Davidsons study (Davidson et al., 2003) an 8-week course in mindfulness meditation was shown to improve immune system performance and was associated with important changes in brain functioning. The predominance of brain activity in meditators, as compared to a wait-list control group, changed from areas of the frontal lobes linked to increased levels of anxiety, anger, and depression to areas of the frontal lobes associated with relaxation, curiosity, enthusiasm, and higher overall levels of positive affect. For overworked graduate students experiencing the stress that the initial study of psychopathology often engenders, the selfdirected empathy of meditation practice might improve the efficacy of clinical training while helping students integrate the emergence of disowned or fragmented experience.

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REFERENCES
Alexander, F. (1931). Buddhist training as an artificial catatonia. Psychoanalytic Review, 18, 129-145. Barrett-Leonard, G. T. (1997). Recovery of empathy: Toward self and others. In A. C. Bohart & L. S. Greenberg (Eds.), Empathy reconsidered: New directions in psychotherapy (pp. 103-120). Washington, DC: American Psychological Association. Bateson, G. (1972). Steps to an ecology of mind. Chicago: University of Chicago Press. Beck, C. J., & Smith, S. (1993). Nothing special: Living Zen. San Francisco: Harper. Benson, H. (1975). The relaxation response. New York: Morrow. Benson, H., Lehmann, J., Malhotra, M., Goldman, R., Hopkins, J., & Epstein, M. (1982). Body temperature changes during the practice of gTum-mo yoga. Nature, 295, 23-26. Bohart, A. C., & Greenberg, L. S. (1997). Empathy in psychotherapy: An introductory overview. In A. C. Bohart & L. S. Greenberg (Eds.), Empathy reconsidered: New directions in psychotherapy (pp. 3-32). Washington, DC: American Psychological Association. Bozarth, J. D. (1997). Empathy from the framework of client-centered theory and the Rogerian hypothesis. In A. C. Bohart & L. S. Greenberg (Eds.), Empathy reconsidered: New directions in psychotherapy (pp. 81102). Washington, DC: American Psychological Association. Bozarth, J. D., Zimring, F. M., & Tausch, R. (2002). Client-centered therapy: The evolution of a revolution. In D. J. Cain & J. Seeman (Eds.), Humanistic psychotherapies: Handbook of research and practice (pp. 147-188). Washington, DC: American Psychological Association. Brazier, D. (1995). Zen therapy: Transcending the sorrows of the human mind. New York: John Wiley. Davidson, R., Kabat-Zinn, J., Schumacher, J., Rosnekranz, M., Muller, D., Santorelli, S., et al. (2003). Alterations in brain and immune functioning produced by mindfulness meditation. Psychosomatic Medicine, 65, 564-570. Dogen. (1976). Shobogenzo (Y. Yokai, Trans.). New York: Weatherhill. Ekman, P. (2001). Telling lies: Clues to deceit in the marketplace, politics, and marriage. New York: Norton. Engler, J. (1993). Becoming somebody and nobody: Psychoanalysis and Buddhism. In R. Walsh & F. Vaughn (Eds.), Paths beyond ego (pp. 118121). Los Angeles: Tarcher/Perigee. Engler, J. (2003). Being somebody and nobody: A reexamination of the understanding of self in psychoanalysis and Buddhism. In J. Safran (Ed.), Psychoanalysis and Buddhism: An unfolding dialogue (pp. 35100). Boston: Wisdom. Epstein, M. (1995). Thoughts without a thinker: Psychotherapy from a Buddhist perspective. New York: Basic Books. Epstein, M. (1998). Going to pieces without falling apart: A Buddhist perspective on wholeness. New York: Broadway Books.

David T. Andersen

501

Eysenck, H. J. (1952). The effects of psychotherapy. Journal of Consulting and Clinical Psychology, 16, 319-324. Eysenck, H. J. (1993). Forty years on: The outcome problems in psychotherapy revisited. In T. R. Giles (Ed.), Handbook of psychotherapy (pp. 3-20). New York: Plenum. Freud, S. (1930). Civilization and its discontents (J. Strachey, Ed.). New York: Norton. Fromm, E., Suzuki, D. T., & DeMartino, R. (1960). Zen Buddhism and psychoanalysis. New York: Harper & Row. Gelso, C. J., & Carter, J. A. (1985). The relationship in counseling and psychotherapy: Components, consequences, and theoretical antecedents. The Counseling Psychologist, 13, 155-433. Gendlin, E. T. (1974). Client centered and experiential psychotherapy. In D. Wexler & L. Rice (Eds.), Innovations in client centered psychotherapy (pp. 211-246). New York: John Wiley. Goleman, D. (2003). Destructive emotions: A scientific dialogue with the Dalai Lama. New York: Bantam Books. Greenberg, L. S. (2002). Integrating an emotion-focused approach to treatment into psychotherapy integration. Journal of Psychotherapy Integration, 12(2), 154-189. Horowitz, M. J. (2002). Self- and relational observation. Journal of Psychotherapy Integration, 12, 115-127. Jordan, J. V. (1997). Relational development through mutual empathy. In A. C. Bohart & L. S. Greenberg (Eds.), Empathy reconsidered: New directions in psychotherapy (pp. 343-351). Washington, DC: American Psychological Association. Kohut, H. (1984). How does analysis cure? Chicago: University of Chicago Press. Kornfield, J. (1993). A path with heart. New York: Bantam. Lesh, T. (1970). Zen meditation and the development of empathy in counselors. Journal of Humanistic Psychology, 10(1), 39-74. Linehan, M. M. (1993). Skills training manual for treating borderline personality disorder. New York: Guilford. Luborsky, L., Crits-Christoph, P., Mintz, J., & Auerbach, A. (1988). Who will benefit from psychotherapy? Predicting therapeutic outcomes. New York: Basic Books. Luborsky, L., Singer, B., & Luborsky, L. (1975). Comparative studies of psychotherapies: Is it true that everyone has won and all must have prizes? Archives of General Psychiatry, 32, 995-1008. Magid, B. (2002). Ordinary mind: Exploring the common ground of Zen and psychotherapy. Boston: Wisdom. Martin, J. R. (1997). Mindfulness: A proposed common factor. Journal of Psychotherapy Integration, 7, 291-312. Masson, J., & Hanly, C. (1976). A critical examination of the new narcissism. International Journal of Psychoanalysis, 57, 49-65. Matsumoto, D., LeRoux, J., Wilson-Cohn, C., Raoque, J., Kooken, K., Ekman, P., et al. (2000). A new test to measure emotion recognition ability: Matsumoto and Ekmans Japanese and Caucasian Brief Affect

502

Empathy, Psychotherapy Integration, and Meditation

Recognition Test (JACBERT). Journal of Nonverbal Behavior, 24(3), 179-209. Orlinsky, D. E., & Howard, K. I. (1986). Process and outcome in psychotherapy. In S. L. Garfield & A. E. Bergin (Eds.), Handbook of psychotherapy and behavior change (3rd ed., pp. 311-384). New York: John Wiley. Pearl, J. H., & Carlozzi, A. F. (1994). Effect of meditation on empathy and anxiety. Perceptual and Motor Skills, 78(1), 297-298. Rogers, C. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology, 21, 95-103. Rosenzweig, S. (1936). Some implicit common factors in diverse methods of psychotherapy. American Journal of Orthopsychiatry, 6, 412-415. Rubin, J. (1996). Psychotherapy and Buddhism: Toward an integration. New York: Plenum. Rubin, J. (2003). A well-lived life: Psychoanalytic and Buddhist contributions. In J. Safran (Ed.), Psychoanalysis and Buddhism: An unfolding dialogue (pp. 387-410). Boston: Wisdom. Schuster, R. (1979). Empathy and mindfulness. Journal of Humanistic Psychotherapy, 19(1), 71-77. Schwartz, J., & Begley, S. (2002). The mind and the brain: Neuroplasticity and the power of mental force. New York: Regan Books. Segal, Z. V., Teasdale, J. D., & Williams, J. M. G. (2001). Mindfulness-based cognitive therapy for depression. New York: Guilford. Shapiro, A. K. (1971). Placebo effects in medicine, psychotherapy and psychoanalysis. In A. E. Bergin & S. C. Garfield (Eds.), Handbook of psychotherapy and behavior change: Empirical analysis (pp. 437-473). New York: John Wiley. Shapiro, S. L., Schwartz, G. E., & Bonner, G. (1998). Effects of mindfulnessbased meditation on medical and premedical students. Journal of Behavioral Medicine, 21, 581-599. Stricker, G., & Gold, J. R. (1996). Psychotherapy integration: An assimilative, psychodynamic approach. Clinical Psychology: Science and Practice, 3(1), 47-58. Stubbs, J. P., & Bozarth, J. P. (1994). The dodo bird revisited: A qualitative study of psychotherapy research. Applied and Preventive Psychology, 3(2), 109-120. Wachtel, P. (1993). Therapeutic communication: Principles and effective practice. New York: Guilford. Watts, A. (1957). The way of Zen. New York: Vintage. Weinberger, J. (2002). Short paper, large impact: Rosenweigs on the common factors movement. Journal of Psychotherapy Integration, 12, 6776. Wellwood, J. (1983). On psychotherapy and meditation. In J. Wellwood (Ed.), Awakening the heart: East/West approaches to psychotherapy and the healing relationship (pp. 43-54). Boston: Shambhala. Wilber, K. (1993). Psychologia perennis: The spectrum of consciousness. In R. Walsh & F. Vaughan (Eds.), Paths beyond ego: The transpersonal vision (pp. 21-33). Los Angeles: Tarcher/Perigee.