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What’s Wrong with This Picture?

As neurobiological research expands to show that mindfulness practices change brain structure and function in meaningful, measurable ways, and clinical research continues to show that it can be helpful in treating a wide range of disorders, how could it not be destined to revolutionize psychotherapy? The main reason is that it requires effort—often a lot more effort than clients, and sometimes even therapists, are willing to muster.

The most compelling positive results of mindfulness practice—the radical shifts in how we experience ourselves and the world—don’t usually come about from casual dabbling. While there are mindfulness practices to fit every lifestyle, including informal practices like mindful walking, showering, driving, and dishwashing, which don’t require taking extra time out of our day to meditate, most people need to set aside time for formal meditation practice to see substantial changes in psychological functioning. This means being willing to open up to unpleasant experience—whether anxiety or restlessness that draws us toward something more entertaining, or intimate encounters with previously split off emotions, including sadness, anger, loneliness, and vulnerability. Our culture doesn’t provide a lot of support for this sort of work. We’re continuously offered distractions in the form of smartphones, iPods, and the like. All signs indicate that we’re rapidly moving in the direction of nonstop entertainment, which will continue to distract us from the contents of our minds. Given this, mindfulness practices may never reach their promise of really transforming psychotherapy, and may remain the domain of a small group of therapists and their clients.

Regardless of whether there’s a mindfulness revolution on the horizon, it’s important to make the technique as clinically relevant as possible. To do so, we must bear in mind several things.

One Size Doesn’t Fit All

My colleagues and I had the privilege a couple of years ago of having the Dalai Lama join us at Harvard Medical School for a conference on Compassion and Wisdom in Psychotherapy. At one point, my codirector, Christopher Germer, asked His Holiness to lead us all in a brief meditation. In his inimitable style, the Dalai Lama reacted as though the request was pretty funny: “I think some of you may want just one single meditation—a simple one, and 100 percent sort of positive. That, I think, impossible.” He went on to explain that there are countless states of mind that lead to suffering, and, consequently, countless meditation practices needed to work with them skillfully. What a given person needs at a given time is a complex matter. He concluded, “Some other sort of companies, they always advertise some simple thing, or something effective, something very cheap. My advertising is just opposite. How difficult, and complicated!”

As with most catchy “new” ideas, integrating mindfulness into psychotherapy has involved reducing a complex set of insights and practices into “some simple thing.” Now that mindfulness has become respectable in psychotherapy circles and is being taught at establishment institutions, we’re beginning to see a more nuanced approach.

Most Western meditation teachers originally emphasized developing concentration (the capacity to step out of the thought stream and focus attention on a chosen object of awareness) and mindfulness per se (open-field awareness, which allows us to be conscious of what the mind is doing at each moment, and thereby see how it creates suffering for itself). Not surprisingly, these skills have been at the heart of the mindfulness practices incorporated into MBSR, DBT, and MBCT, out of which most other mindfulness-based treatments evolved. But these are only a couple of the skills that 2,500 years of systematic mind training in Asia has identified.

More recently, Western meditation teachers began emphasizing other practices, designed to develop different mental faculties, such as metta (loving-kindness practice, to cultivate an accepting, loving attitude toward oneself and others), tonglen (giving-and-taking practice, to allow us to work skillfully with painful emotions), and compassion practices from Tibetan and other traditions.

Following suit, Western clinicians and researchers are increasingly exploring how these and other practices can be adopted into psychotherapy, expanding the range of interventions loosely organized under the “mindfulness” banner. They’re even beginning to pay attention to ethics, which in Buddhist traditions are seen as a necessary foundation for any meditation practice. For example, Barbara Fredrickson, who introduced the Broaden and Build model of well-being in Positive Psychology, has shown that loving-kindness (metta) practices make people demonstrably happier. This upward shift in positive emotions increases their environmental mastery, improves their relations with others, enhances their self-reported health and life satisfaction, and reduces depressive symptoms. Kristin Neff, a pioneer in studying self-compassion, has shown that people with more self-compassion are less anxious and depressed, have greater emotional intelligence, more capacity for perspective, and experience more happiness, optimism, curiosity, and positive affect. She and Germer have developed and tested a standardized 8-week Mindful Self-Compassion therapy group, incorporating a number of compassion practices, with promising results. On a related track, in the United Kingdom, professor Paul Gilbert, founder and president of The Compassionate Mind Foundation, has developed Compassion Focused Therapy. This method uses variations on mindfulness and Tibetan Buddhist compassion practices to treat a variety of difficulties, but especially depression, a disorder in which compassion toward oneself is sorely lacking.

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