I'm interviewed on religion journalist Eileen Flynn's blog on mindfulness, psychology, and parenting here.
The Buddha, Jon Kabat-Zinn, and Mindfulness-Based Cognitive Therapy: Personal Concerns Leading to New Therapeutic Innovations
According to the Pali Canon (the oldest collection of Buddhist texts) the Historical Buddha discovered and formulated mindfulness meditation as a result of wanting to overcome his profound fear of sickness, aging, and his inevitable death. Buddhist mythology describes the Historical Buddha as a rich, and somewhat sheltered prince. When he first comes in contact with people who are sick, aging, and have died he is terrified. And for the next 6 years of his life he tries the main spiritual and religious methodologies of his time, achieves great attainments, but never fully overcomes the raw terror of death.
Finally, he resolves to sit in meditation until he finds a way to cultivate equanimity with the fact that he will eventually die. And thus mindfulness meditation was created over 2,000 years ago. The Pali Canon described the Buddha as wanting to find a new way to deal with some of the universal givens of human existence (e.g. sickness, aging, and death). These Pali texts (Pali is a dialect of Sanskrit) were the first works to discuss mindfulness meditation, and one such Pali text that describes this meditative process in great detail is the Mahāsatipatthāna Sutta (Gotama, 1995).
Just as the Buddha was unsatisfied with earlier established methods of his day, Drs. Jon Kabat-Zinn, John Teasdale, Marsha Linehan, and Steven Hayes have all described how deficiencies in dominant forms of medicine and therapy led them to develop their leading contemporary therapeutic approaches that seek to utilize mindfulness, which was first proposed in the Pali Canon.
In my blog last week, I talked about how Marsha Linehan and Steven Hayes created Dialectical Behavior Therapy (DBT) and Acceptance and Commitment Therapy (ACT), respectively, based on their own personal spiritual interests, struggles, and dissatisfactions with established cognitive and behavioral approaches to therapy. And interestingly, personal influences also led to the clinical innovations of Mindfulness-Based Stress Reduction (MBSR) and Mindfulness-Based Cognitive Therapy (MBCT), which have become leading empirically supported treatments in biological medicine and mental health.
Hearing a lecture by Zen Buddhist priest Philip Kapleau while he was still a graduate student in molecular biology led Jon Kabat-Zinn to develop a life-long personal interest in Buddhist meditation and yoga, and to eventually create MBSR (Simon & Wylie, 2004). After attending a two-week vipassanā (mindfulness) meditation retreat, he returned to the hospital where he was working and created a program for chronic pain patients based on his meditation practice that eventually evolved into MBSR (Simon & Wylie, 2004). Kabat-Zinn believed that mindfulness could improve the treatment of chronic pain even when established medical protocols had often proven insufficient. Kabat-Zinn’s MBSR is designed as an 8-week course that typically meets once a week in a psycho-educational format with the introduction and practice of different MBSR techniques that he originally adapted from his own personal practice and conception of Buddhism and yoga (Kabat-Zinn, 1990, 1994). MBSR was not initially designed or intended to be a psychological intervention in mental health settings, but Kabat-Zinn’s approach came to strongly influence many leading therapeutic approaches that seek to integrate mindfulness into their therapy work (e.g., MBCT, DBT, ACT).
The founders of Mindfulness-Based Cognitive Therapy (MBCT), Drs. Zindel Segal, Mark Williams, and John Teasdale, initially had varying levels of personal interest in Buddhism before creating MBCT (Segal, Williams, & Teasdale, 2002). Professionally, they were moved to explore mindfulness for the treatment of depression because they were concerned about high rates of relapse for people who had used traditional treatments for depression. Of the three founders of MBCT, John Teasdale was initially the most personally interested in Buddhism, and he credits his personal interest in Buddhism as an inspiration for his clinical and research work (Segal, Williams, & Teasdale, 2002).
Segal, Williams, and Teasdale all share that they initially believed their training as psychologists would be sufficient for them to train others in the practice of mindfulness (Segal et al., 2002). They relate, however, that when they initially tried to teach mindfulness without having their own mindfulness practice their seminars were extremely unsuccessful, and they subsequently implemented Kabat-Zinn’s admonition that to teach mindfulness they must first have a strong mindfulness practice (Segal et al., 2002). Teasdale, Segal, and Williams (1995) defined their mindfulness approach as a new, innovative form of cognitive therapy serving to inoculate against the relapse of depression, and contrast their methodology against traditional cognitive therapy: “In the case of cognitive therapy, these alternative “views” probably involve more of an active “coping and controlling” stance than the views implicitly created in mindfulness practice (p. 38).”
Since its origins, Buddhism has been appreciated by some leading psychologists as a way to advance the discipline of psychology. In the early 1900s when the Buddhist monk Anagarika Dharmapala made his third visit to the United States and attended a lecture at Harvard delivered by William James, the seminal scientist urged Dharmapala to speak on Buddhism declaring, “You are better equipped to lecture on psychology than I” (Fields, 1992, p. 135). After Dharmapala spoke to Dr. James’ class, James declared to his students, “This is the psychology everybody will be studying twenty-five years from now” (p. 135). The work of Drs. Jon Kabat-Zinn, John Teasdale, Marsha Linehan, and Steven Hayes are perhaps examples of how James’ prediction that Buddhism would become the future of psychology may now be coming true.
Fields, R. (1992). How the swans came to the lake: A narrative history of Buddhism in America. Boston, MA: Shambhala Publications.
Gotama, S. (1995). Mahāsatipatthāna Sutta: The greater discourse on the foundations of mindfulness. In M. Walshe (Trans.), The long discourses of the Buddha: A translation of the Dīgha Nikāya (pp. 335-350). Somerville, MA: Wisdom Publications.
Kabat-Zinn, J. (1990). Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness. New York, NY: Delta.
Kabat-Zinn, J. (1994). Wherever you go, there you are. New York, NY: Hyperion.
Segal, Z., Williams, J. M., & Teasdale, J. (2002). Mindfulness-based cognitive therapy for depression: A new approach to preventing relapse. New York, NY: Guilford Press.
Simon, R., & Wylie, M. S. (2004, November/December). The power of paying attention: What Jon Kabat Zinn has against “spirituality”. [Electronic Version]. Psychotherapy Networker. Retrieved August 1, 2013, from http://www.psychotherapynetworker.org/populartopics/leaders-in-the-field/521-the-power-of-paying-attention
Teasdale, J., Segal, Z., & Williams, J. M. (1995). How does cognitive therapy prevent depressive relapse and why should attentional control (mindfulness) training help? Behaviour Research and Therapy, 33, 25-39.
Last week I wrote about Viktor Frankl and his existential approach to psychology. Frankl’s approach arose for him based on three years he spent in concentration camps such as Auschwitz and Dachau. Frankl’s father, mother, brother and wife were all killed; he and his sister were the only survivors in his family.
I think one reason Frankl’s theories and therapeutic approach have so much meaning for so many people is because he actually endured the unimaginable. And Frankl, a psychiatrist, spoke openly about human phenomenon such as art and love. In fact, he felt that art and love were vehicles to transform clinical problems (e.g. art and love help with things like depression, anxiety, trauma etc.). Sadly, we live in an era of increasingly brief, standardized, manualized, de-personalized therapy. Some of that is a function of insurance companies, and some of it is probably a function of our quick-fix desires of our wider society.
Frankl’s transformation of his personal suffering, and using his profound suffering to create a unique therapeutic approach made me think of other leading theorists and clinicians who have created a new form of therapy based on their own personal suffering.
Dr. Marsha Linehan created Dialectical Behavior Therapy (DBT; Linehan, 1993). DBT is now considered the therapy of choice for Borderline Personality Disorder. DBT is also being used successfully for other concerns, such as substance addiction.
Borderline Personality Disorder is a very challenging situation characterized by a history of intense, unstable relationships and life choices. Not long ago, Marsha Linehan, the “guru” of DBT had the courage to share that she herself had struggled for years with Borderline Personality Disorder and was hospitalized due to numerous suicide attempts and self-injurious behavior that included cutting herself, head banging, and burning herself (Carey, 2011). Linehan credits her Roman Catholic religious faith, prayer, and personal interest in Buddhism with enabling her to survive and create DBT (Carey, 2011; Robins, 2002).
Dr. Steven Hayes was a widely published, successful professor and researcher. But at the same time Dr. Hayes also suffered debilitating panic attacks that threatened his academic career. Hayes has stated publicly that an interest in Buddhist philosophy, meditation, and other forms of religion and spirituality helped him overcome his Panic Disorder and create Acceptance and Commitment Therapy (ACT; Cloud, 2006).
ACT was initially designed to primarily address anxiety-related symptoms and disorders. ACT has emerged to be used successfully for a range of diverse problems including chronic pain, substance abuse, obesity, cancer management, schizophrenia, psychosis, and PTSD (Bach & Hayes, 2002; Bach, Hayes, & Gallop, 2012; Gundy, Woidneck, Pratt, Christian, & Twohig, 2011; Walser & Westrup, 2007).
Drs. Frankl, Linehan, and Hayes each endured profound suffering. And each transformed their suffering to create influential therapeutic approaches. Their work demonstrates that out of profound suffering we can find ways to help other people. And sometimes, by helping ourselves, we can help others as well.
Bach, P., & Hayes, S. C. (2002). The use of acceptance and commitment therapy to prevent the rehospitalization of psychotic patients: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 70(5), 1129-1139. doi:http://dx.doi.org/10.1037/0022-006X.70.5.1129
Bach, P., Hayes, S. C., & Gallop, R. (2012). Long-term effects of brief acceptance and commitment therapy for psychosis. Behavior Modification, 36(2), 165-181. doi:http://dx.doi.org/10.1177/0145445511427193.
Carey, B. (2011, June 23). Expert on mental illness reveals her own fight. [Electronic Version]. The New York Times. Retrieved July 29, 2011, from http://www.nytimes.com/2011/06/23/health/23lives.html?_r=1&pagewanted=all
Cloud, D. (2006, February 13). The third wave of therapy. [Electronic Version]. Time. Retrieved July 29, 2011, from http://www.time.com/time/magazine/article/0,9171,1156613,00.html
Gundy, J. M., Woidneck, M. R., Pratt, K. M., Christian, A. W., & Twohig, M. P. (2011). Acceptance and commitment therapy: State of evidence in the field of health psychology. The Scientific Review of Mental Health Practice: Objective Investigations of Controversial and Unorthodox Claims in Clinical Psychology, Psychiatry, and Social Work, 8(2), 23-35. Retrieved from http://search.proquest.com/docview/928984322?accountid=10868
Linehan, M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press.
Robins, C. (2002). Zen principles and mindfulness practice in Dialectical Behavior Therapy. Cognitive and Behavioral Practice, 9, 50-57.
Walser, R. D., & Westrup, D. (2007). Acceptance and commitment therapy for the treatment of post-traumatic stress disorder and trauma-related problems: A practitioner’s guide to using mindfulness and acceptance strategies. Oakland, CA: New Harbinger Publications.
Imagine that you are having the absolute worst moment of your life. How would you handle it, if you were experiencing inconceivable sadness and emotional pain? What helps some people be able to endure the unendurable? How are some people able to transform the most traumatic of human experiences? These are the subjects I was discussing with a good friend the other day. In our conversation about suffering, and different ways to transform suffering, we started discussing the influential existential therapist Dr. Viktor Frankl. I was so intrigued by our discussion that it made me want to revisit this seminal thinker. There are literally hundreds of different kinds of therapy, and Dr. Frankl is one of the foundational theorists for existential therapy. Existential therapy seeks to confront suffering head-on. Frankl referred to his therapeutic approach as logotherapy.
Dr. Viktor Frankl summarizes the therapeutic approach of logotherapy, both in terms of counseling and philosophy, in his seminal work Man’s search for meaning: An introduction to Logotherapy when he asserts, “Each man is questioned by life; and he can only answer to life by answering for his own life; to life he can only respond by being responsible” (1992, p. 113-114). The linguistic etiology of the word “logotherapy” reveals the essence of this influential therapeutic approach. The Latin word logos literally means “word” and in seeking to facilitate psychological transformation Frankl calls for therapists to help their clients in discerning meaning in their lives and the circumstances they are confronted with.
Frankl’s psychotherapeutic interventions and philosophy were born directly out of his own extraordinary life experiences. He spent three years during World War II in Auschwitz, Dachau and other concentration camps. Frankl’s father, mother, brother and wife were all killed; he and his sister were the only survivors in his family. As a result of this immense suffering Frankl wondered why some prisoners in the concentration camps not only survived but also grew psychologically stronger while others languished away in despair and anger. Frankl concluded that if people had a meaning that sustained them they could endure even the deepest forms of suffering and emerge strengthened and transformed. From this psychological insight logotherapy and its therapeutic techniques arose.
Frankl described logotherapy as “meaning-centered psychotherapy” and believed it was superior to other forms of treatment (p. 104). Interestingly, he openly championed his style of therapy as being superior to psychodynamic (Freudian-based) approaches, which were extremely popular when logotherapy developed, arguing, “logotherapy defocuses all the vicious-circle formations and feedback mechanisms which play such a great role in the development of neuroses” (p. 104). Frankly believed that psychodynamic approaches actually entrenched and exacerbated clients’ suffering.
Clinically, Frankl urged therapists to focus on meaning making, and not rely on Freudian assumptions which posited that human existence was centered on satisfying pleasure urges—such was Frankl’s interpretation of psychodynamic theory. While Frankl acknowledged that his depiction of psychodynamic theory was at times “an oversimplification” he also suggested that the Freudian approach of unearthing hidden conflicts could therapeutically devolve, resulting in the sincere beliefs and intentions of the client being debased and devalued (p. 104).
Frankl further openly contrasted his therapeutic style with Freudian approaches by arguing that people’s primary need in life was to fulfill their highest meaning, as opposed to merely seeking the gratification of hidden drives and instincts or reconciling the conflicting pulls of the id, ego and superego. For Frankl, suffering could be extremely therapeutically beneficial. He postulated, “suffering may well be a human achievement, especially if the suffering grows out of existential frustration” (p. 108).
Thematically, Frankl advocated a client-centered approach echoed in the work of Carl Rogers. In logotherapy responsibility for therapeutic transformation rests ultimately with the client—not the therapist. Frankl notes, “A logotherapist is the least tempted of all psychotherapists to impose value judgments on his patients, for he will never permit the patient to pass to the doctor the responsibility of judging” (p. 114). Frankl simultaneously resists the interpretation-based approach utilized by psychodynamic approaches and the guided, structured approach of Cognitive Behavioral Therapy (CBT; arguably the most popular form of therapy today). I think it could further be argued that Frankl’s championing of a client discovering his or her own individual meaning is particularly skillful in cross-cultural counseling sessions as it is open and supportive of the role of individual diversity in therapy.
Significantly Frankl’s therapeutic philosophy and techniques do share some clinical methodologies with contemporary interventions that are derived from other psychological paradigms. In contrasting logotherapy to Freudian-derived methods, Frankl asserts that his style of treatment focuses on the “future” and is “less retrospective and less introspective” (1992, p. 104). He also believes that thoughts shape one’s experience of reality and by altering thought patterns one can dramatically change his or her reality. These foundational characteristics of logotherapy are also hallmarks of Cognitive Therapy. Though similar to Cognitive Therapy in some important ways, Frankl differs in his relentless focus on ascertaining existential meaning making. I remember talking with a psychologist once who defined his therapeutic approach as CBT (Cognitive Behavioral Therapy). When I asked him how he dealt with the question of meaning for clients who were suffering he said simply, “I don’t do meaning.” Dr. Frankl would certainly not agree with that psychologist’s therapeutic approach, and neither would I!
Frankl’s philosophy and treatment goals are shared by some emerging and innovative theorists. Summarizing the chief treatment objective in logotherapy, Frankl suggests “The more one forgets himself—by giving himself to a cause to serve or another person to love—the more human he is and the more he actualizes himself….In other words, self-actualization is possible only as a side-effect of self-transcendence” (p. 115). Frankl’s sentiments echo the research, treatment techniques and philosophical underpinnings of leading contemporary positive psychologists who call on people to find happiness in stepping outside themselves through the immersion in rewarding, enriching activities and relationships (Csikszentmihalyi, 1990). Though a subject for another blog post, I also believe Frankl’s idea of “self-transcendence” is very close to the Buddhist idea of no-self.
Frankl would likely also be at variance with the modern predominance of psychopharmacology and the emergence of the contemporary biological paradigm and some of its assumptions and treatment methodologies, declaring “I consider it a dangerous misconception of mental hygiene to assume that what man needs in the first place is equilibrium or, as it is called in biology, ‘homeostasis,’ i.e. a tensionless state” (p. 110). For example, an oft-cited recent study found that antidepressant use among people in the United States has almost doubled from 1996 to 2005, along with a concurrent rise in the use of other psychotropic medications (Olfson & Marcus, 2009). This increase seemed to span virtually all demographic groups; over 10% of people over the age of 6 are now receiving anti-depression medication (2009). Significantly, these researchers further noted that clients who were treated with antidepressants became more likely to also receive treatment with antipsychotic medications and less likely to undergo talk therapy. Frankl’s lamentation that medical caregivers fail to recognize the therapeutic value in suffering emerges as strikingly prescient, “It may well be that interpreting the first in terms of the latter motivates a doctor to bury his patient’s existential despair under a heap of tranquilizing drugs” (p. 108).
To be sure, psychiatric medications do help many people. But I also believe we are meaning-making beings. Frankl’s enduring and transforming of his experience in the concentration camps points to something essential to human nature. And I believe Dr. Frankl is correct when he describes a process of forgetting ourselves to transform ourselves. It’s worth noting too that Freudian-based approaches have evolved a lot since Freud first proposed them over a 100 years ago. Though a topic for a future blog post, Freud was a pioneer and not wrong about everything. And some recent research has affirmed the value of psychodynamic approaches. Philosophies that undergird therapy do not have to be mutually exclusive. And I also believe Dr. Frankl had a lot of wisdom in his approach to therapy.
Csikszentmihalyi, M. (1990). Flow: The psychology of optimal experience. New York: Harper Collins.
Frankl, V. (1992). Man’s search for meaning: An introduction to Logotherapy. Boston: Beacon Press.
Olfson, M., & Marcus, S. (2009). National patterns in antidepressant medication treatment. Archives of General Psychiatry, 66, 848-856.
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