An ancient spiritual practice is finding new uses in the treatment of mental illness.
The systematic method of regulating attention known as meditation is now being incorporated into psychotherapeutic practice and linked in surprising ways to other healing traditions, including cognitive behavioral therapy. The most highly developed forms of meditation are associated with Buddhism, but there are parallels in other spiritual and religious traditions, as well as modern secular versions under the names of relaxation response training or mindfulness meditation.
One typical practice is to choose a word, sound, or short phrase (sometimes called a mantra) and repeat it with each breath while sitting in a relaxed position with eyes closed, while calmly dismissing distracting thoughts and feelings. In the slightly different mindfulness meditation, there is less emphasis on the mantra. Practitioners sit and remain aware of their breathing while observing thoughts and feelings as they come and go in a quiet and detached way. If they notice that their attention is wandering, they are supposed to observe the process without trying to disengage from it and simply return to awareness of their breathing. The rule is not to fight it — whatever internal state "it" may be — and not to encourage it either. The aim is to suspend habits of selecting, judging, and interpreting, and attend to the present moment without allowing oneself to be distracted by fantasies, memories, and anxieties.
There is evidence that these practices have distinct effects on the brain. In one study, brain scans indicated that Buddhist monks who were longtime meditators, compared with controls who had just a week of training, showed a high proportion of a type of brain wave that reflects large-scale coordination of neural circuits. In another recent study, researchers measured brain electrical activity before, immediately after, and four months after a two-month course in mindfulness meditation. They found persistent increased activity on the left side of the prefrontal cortex, which is associated with joyful and serene emotions. They also found increased antibody responses to an influenza vaccine. Studies are now looking at the effects of meditation on the amygdala, the brain's fear center, and the caudate nucleus, which is associated with obsessional thoughts and compulsive behavior.
In meditative traditions, the purpose of drawing attention away from the outside world and abandoning habitual patterns of perceiving and thinking is to facilitate personal change. The focused attention, self-forgetfulness, and heightened awareness of body states are supposed to open the mind to decreased preoccupation with one's own suffering, a move from self-deception to self-understanding, and resulting changes in attitudes and behavior.
The resemblance to the aims of psychotherapy is no accident, as practitioners of both traditions increasingly recognize. But the psychotherapeutic tradition now taking meditation most seriously, to the surprise of some, is cognitive behavioral therapy.
Behavioral theory and therapy in their original forms were concerned only with stimulus and response and tangible rewards and punishments. Making almost no reference to the mind or internal experience and concentrating on action, behaviorism was seemingly at the farthest possible remove from meditation. But eventually the need to take account of thoughts and feelings became apparent, and behavior therapy was enhanced by cognitive techniques — testing, questioning, and correcting irrational thinking, and the use of observational learning and problem-solving strategies.
The purpose of cognitive behavioral therapy is to change self-defeating ways of thinking about the world, the self, and the future. Cognitive therapists analyze what they call thought schemas, underlying attitudes that are not explicit and mostly out of awareness: Everyone must like me or I will die lonely and unmourned; if I'm not perfect I am a failure; it is always best to assume the worst; anyone who tells me what to do is saying that I am incompetent. These schemas are the basis for automatic misinterpretations of everyday situations: My heart is beating so fast that I must be having a heart attack; he will snub me, so I must cross the street to avoid him.
Pessimistic and self-deprecating explanations become self-fulfilling prophecies, as they result in selective attention to anxiety-provoking and depressing experiences. The cognitive therapist helps patients bring schemas and automatic thoughts to awareness so that they can be questioned and alternatives can be offered.
Now some therapists have gone further, contemplating a merger between cognitive techniques and meditation that they call the "third wave" of cognitive behavioral therapy. Some names given to the new approaches are dialectical behavior therapy, acceptance and commitment therapy, and mindfulness-based cognitive therapy.
The new tendency began with dialectical behavior therapy, which uses standard behavioral and cognitive techniques along with mindfulness meditation in a form of individual and group treatment originally developed to prevent self-mutilation and suicide attempts in women with borderline personality. Dialectical behavior therapy has also been used for eating disorders, addictions, and other conditions. Marsha Linehan, the originator of the technique, refers to a "dialectic of acceptance and change" in which meditation serves as a means for the patient to accept feelings that she has been rejecting because family members and friends have declared them unjustified or invalid.
Acceptance and commitment therapy, developed by Stephen Hayes and others, further breaks down the distinction between cognitive behavioral therapy and older spiritual teachings. Its motto is, "Control is the problem, not the solution." The idea is that to suppress or avoid bad feelings and depressing thoughts only makes matters worse by, in effect, committing oneself to an internal war. The goal of therapy should be to change the patient's relationship to symptoms rather than treat them as an enemy to be eliminated. The patient must accept without struggling — "don't fight it" — anxious and depressing thoughts, even hallucinatory voices. In that way, according to the theory, they will eventually lose their power. This truce in the internal battle is well captured by what the Buddha is supposed to have said: "Pitting what you like against what you do not like is a disease of the mind."
Acceptance and commitment therapists oppose what they call cognitive fusion and experiential avoidance. Cognitive fusion is an effect of our need for networks of words and concepts. For example, a person constantly worries about or is even terrified by many places and situations that bear some resemblance to the situation in which a panic attack occurred. Trying to prevent or suppress this cognitive fusion directly is impossible because it brings to mind what you are trying to avoid. A favorite example is the impossible demand, "Do not think about a white bear." A person who tries not to feel anxious will become anxious about the anxiety; a person trying hard to sleep will only make the insomnia worse.
The solution recommended is to loosen the grip of language and generalization by promoting the opposite — experiential acceptance and cognitive defusion. Cognitive behavioral therapists have always believed that the first step is distancing oneself from depressive and anxious thoughts, treating them objectively as events in the world — much in the way meditation works. Cognitive therapists go on to question the content of the thoughts and test their validity in real-life situations, but some research suggests that the distancing has the most profound therapeutic effects.
Acceptance and commitment therapy rejects the assumption that what needs to be changed is the content of a thought or feeling. Anxiety is not the problem in anxiety disorders, according to this theory, and thoughts are not the problem in thought disorders. The reason for wanting relief from anxiety or depression is to live a better life. But trying to eliminate specific symptoms does not accomplish that end.
The alternatives include meditation and a variety of mental exercises, metaphors, and stories that resemble Zen paradoxes and parables. For example:
Think of your good feelings and your bad feelings as the players holding the white and black pieces in a chess game. Struggling against your bad feelings means joining a meaningless and futile contest with yourself.
Imagine your situation as a tug-of-war in which you are pulling harder and harder against an opponent who is dragging you toward a pit. Instead you have to drop the rope.
Sit and picture thoughts passing through your mind in the form of words on signs held by people in a parade you are watching from a reviewing stand. Eventually you may find that you can't keep your thoughts on that kind of helpful distance. Back up and try to recall what you were thinking when the shift occurred. Then try again.
Imagine that you are connected to a device that infallibly detects anxiety. Would this help you avoid or control the anxiety, or would the effort simply create more discomfort?
Eventually, commitment is supposed to follow acceptance. The therapist uses standard cognitive behavioral therapy techniques such as establishing goals for behavior change and working toward those goals in small steps. But the emphasis is on what patients must do, not on what they must not do, and the aim is to enhance the overall quality of life rather than concentrate on eliminating specific kinds of behavior. For example, to establish goals, the therapist might ask a patient to write out what she would most like to hear in a eulogy delivered at her funeral.
Mindfulness-based cognitive therapy uses similar methods to prevent relapse in depressed patients and avoid the need for indefinite use of antidepressant drugs. It is based on the idea that a patient who has recovered from depression remains vulnerable because of associations the mind has learned. Any sadness, disappointment, or frustration reactivates pessimism, self-deprecation and gloomy generalizations about failure, weakness, and worthlessness, which in turn exacerbate the mood in a vicious downward spiral. It happens in the same way that reminders of the drug experience put recovered addicts in peril of re-addiction.
The therapy is conducted in weekly group sessions, with daily homework, several months after the patient has recovered and stopped taking antidepressant drugs. The therapist helps patients disengage from self-defeating thoughts. Instead of struggling against depressive thoughts, patients are asked to adopt an attitude of detached "kindly curiosity" that resembles the experience cultivated in mindfulness meditation. They are taught to notice when mood begins to change and break the chain of depressive thinking by observing thoughts, feelings, and physical sensations as they come and go.
Both meditation and the psychotherapeutic methods that incorporate it have been used in a variety of ways to improve physical and mental health. Meditation techniques are applied to relieve discomfort in physical conditions including psoriasis, irritable bowel syndrome, fibromyalgia, and rheumatoid arthritis. A combination of yoga and meditation with diet has been claimed to reverse coronary artery disease. Mindfulness meditation has also been used to enhance well-being in people with early breast and prostate cancer; to decrease criminal offenses committed by juvenile delinquents; to help women with binge eating disorder; and to relieve stress and depression in people caring for dementia victims. It has been proposed for the treatment of addiction, phobias, and obsessive-compulsive disorder.
Controlled studies have shown that dialectical behavior therapy can lower the rate of self-mutilation and suicidal behavior in women with borderline personality disorder. In one study, acceptance and commitment therapy helped psychotic patients dismiss their hallucinatory voices and reduced the rehospitalization rate by 50% over four months. In another study, depressed patients who received mindfulness-based cognitive therapy were only half as likely to relapse as those who had only standard counseling and medication. These methods have also been used in the treatment of eating disorders, work-related stress, and addictions.
Different types of psychotherapy are becoming more alike as they borrow ideas and techniques from one another, and therapists may use several different approaches with a single patient. For example, the methods of cognitive therapists are often compared to the analysis of rationalization, denial, and other ego mechanisms of defense in psychodynamic therapy. This tendency toward eclecticism and integration is encouraged by evidence that many forms of psychotherapy are equally effective. The incorporation of practices derived from meditation in the third wave of cognitive behavioral therapy could be another stage in a historical process that is transforming psychotherapy.
Acceptance and Commitment Therapy: The Web Site www.acceptanceandcommitmenttherapy.com
Center for Mindfulness in Medicine, Health Care, and Society, University of Massachusetts Medical School508-856-2656www.umassmed.edu/cfm
Mind/Body Medical Institute617-632-9543www.mbmi.org
National Center for Complementary and Alternative Medicine, National Institutes of Health888-644-6226 (toll free)nccam.nih.gov
Bach P, et al. "The Use of Acceptance and Commitment Therapy to Prevent the Rehospitalization of Psychotic Patients: A Randomized Controlled Trial," Journal of Consulting and Clinical Psychology (Oct. 2002): Vol. 70, No. 5, pp. 1129–39.
Brown KW, et al. "The Benefits of Being Present: Mindfulness and Its Role in Psychological Well-Being," Journal of Personality and Social Psychology (April 2003): Vol. 84, No. 4, pp. 822–48.
Hayes SC, et al., eds. Mindfulness and Acceptance: Expanding the Cognitive-Behavioral Tradition. Guilford Press, 2004.
Kabat-Zinn J, et al. "Effectiveness of a Meditation-Based Stress Reduction Program in the Treatment of Anxiety Disorders," American Journal of Psychiatry (July 1992): Vol. 149, No. 7, pp. 936–43.
Teasdale JD, et al. "Prevention of Relapse/Recurrence in Major Depression by Mindfulness-Based Cognitive Therapy," Journal of Consulting and Clinical Psychology (Aug. 2000): Vol. 68, No. 4, pp. 615–23.
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