ÐÏࡱá>þÿ kmþÿÿÿfghijÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿì¥Áa ð¿ñcjbjbdd œ|eeeW*aÿÿÿÿÿÿˆªªª”>h\\\4Z þÙþÙþÙhfÚ¬Û¬Z 6ÖÊÞÊÞFßßßëßëßëß­¯¯¯¯¯¯, R^ªÛ\ëßëßëßëßëßÛ‹ö\\ßßÛð‹ö‹ö‹öëß \ß\ß­‹ö4Ä–Š4Ú‚\\ëß­‹ö‹öâ €\\‰ ŸÞ åKÿÁþÙì„ © ‰ $ 06¿ Ê‹ö,‰ ‹ö\Z Z €¹þÙZ Z þÙMindfulness as Cognitive Training a Contribution from Early Buddhist Thought Michael Wayne Chaskalson School of Education, University of Wales, Bangor September 2005 This dissertation is submitted in part fulfilment of the requirement for the degree of M.A. of the University of Wales Declarations and Statements This dissertation is submitted in part fulfilment of the requirement for the degree of M.A. Signed…………………………………………… Date……………………… This work has not previously been accepted in substance for any degree and is not being concurrently submitted for any degree other than the one for which it is now submitted namely Master of Arts of the University of Wales. Signed…………………………………………… Date……………………… This dissertation is the result of my own independent investigation, except to the extent stated in the acknowledgements, and except for what is explicitly attributed in the text to other sources. Signed…………………………………………… Date……………………… I hereby give consent for my dissertation, if accepted, to be available for photocopying (subject to copyright regulations) and for inter-library loan, and for the title and summary to be made available to outside organisations Signed…………………………………………… Date…………………… Acknowledgements I want to express my sincere thanks to the many people who supported me in writing this dissertation, especially: Rebecca Crane and Robert Morrison: insightful supervisors who were open-handed with their time and knowledge. John Teasdale, for stimulating hours of fruitful discussion on Buddhism, the MBAs and contemporary psychology; and for patiently, kindly and generously helping me to develop my teaching ability and understandings. Dharmachari Ruchiraketu, for warm and encouraging support as a teaching colleague. Urgyen Sangharakshita, for his tireless sharing of Buddhist insight. Colin Baker, whose helpful reading of the text was over and above the call of duty. Annette, for her love, unfailing support, – and proof-reading! Abstract Mindfulness as Cognitive Training: a Contribution from Early Buddhist Thought This comparative study investigates the contemporary use of mindfulness as a clinical intervention alongside the way in which mindfulness was conceived in early Buddhist thought, drawing out convergences and divergences between both contexts. It is especially concerned to investigate whether the early Buddhist conception of mindfulness might cast useful light on contemporary clinical theory and practice. In Chapter 1, the rationale, methodology and focus of the study are described, the research issues are presented and the literary research method that the study uses is discussed. Chapter 2 introduces the concept of mindfulness, showing how it is understood firstly in the Mindfulness-Based Approaches (MBAs) and secondly in early Buddhist thought. Chapter 3 provides a brief overview of the main clinical approaches based in mindfulness and reviews the current research literature in the field. It considers possible mechanisms that might account for the effects of mindfulness training in bringing about symptom reduction and introduces the mindfulness practices taught in MBAs. It shows how the embodiment of mindfulness by the teacher bears upon what is learned and it describes the MBA approach to cognitive training Chapter 4 investigates mindfulness in early Buddhist thought. It shows that mindfulness in that context was conceived as a method of cognitive training aimed at bringing about a change in the way in which the world is perceived. It examines the issue of mental elaboration as it was considered in early Buddhism and discusses the issue of present moment awareness in early Buddhist thought and practice, focusing in particular on the Buddha’s discourse on the Four Foundations of Mindfulness. It notes that that the early Buddhist approach to mindfulness focuses to a considerable degree on the issue of cognitive training, especially by way of training one’s apperceptions. Chapter 5 provides a summary of the study and brings the main argument to conclusion. It considers the implications of the study for the ways in which mindfulness is used and taught as an approach. It makes recommendations for future theoretical development and suggests lines of further research. CONTENTS Declarations and StatementsiAcknowledgementsiiAbstractiiiTable of ContentsivAbbreviationsviIntroductionviiChapter OneRationale And Methodology1The Research Issue1The Context and Background of the Research2The Research Questions This Study Addresses3Methodology6The Focus of this Study7Data Collection8Analysis of the Data Collected11Chapter TwoMindfulness in MBAs and Buddhism13What is Mindfulness from the Perspective of the Mindfulness-Based Approaches?13The Buddhist Perspective on Mindfulness19Chapter ThreeThe Application of Mindfulness in Clinical Contexts27The Mindfulness-Based Approaches27The Current Research Basis of MBSR and MBCT30How Mindfulness May Help in the Clinical Context32Exposure33Self-Management34Relaxation34Acceptance35Cognitive Change36The Structure of a Mindfulness Course and a Review of the Practices Used39A Typical Mindfulness Course40The ‘raisin exercise’40The body-scan meditation42Sitting meditation43Mindful movement44Mindful walking45Three-minute breathing space45The Mindful Didactic Style46Cognitive Training in MBAs48Chapter FourMindfulness in Early Buddhist Thought52Mindfulness and Mental Elaboration52Conclusion76Chapter FiveConclusion78Summary of the Study78Conclusions85Bibliography86Appendix Abbreviations Used in the Study ACT Acceptance and Commitment Therapy CFM Center for Mindfulness CFS Chronic Fatigue Syndrome DBT Dialectical Behaviour Therapy IMSCaR Institute of Medical and Social Care Research MBAs Mindfulness-Based Approaches MBCT Mindfulness-Based Cognitive Therapy MBSR Mindfulness-Based Stress Reduction NICE National Institute for Clinical Excellence RCT Randomised Controlled Trial RP Relapse Prevention UK United Kingdom USA United States of America Introduction The aim of this study is to investigate the relationship between mindfulness as it is currently considered in the context of clinical practice and as it was conceived in early Buddhist thought. It asks whether the early Buddhist conception of mindfulness might cast useful light on the use of mindfulness in the contemporary clinical context. Coming from a long personal background of Buddhist study and practise, my own more recent investigations of mindfulness in the clinical context have enriched my Buddhist practice. This study sets out to investigate whether this might be a two-way street. Could mindfulness-based clinical interventions be further enriched by an investigation of Buddhist ideas and practices? As will be shown, contemporary teachers of mindfulness in the clinical context tend, with good reason, to underplay the Buddhist background to mindfulness practice. Nonetheless, the question arises of whether an examination of that background might not yield valuable information. What might Buddhism, with its 2,500 year history of mindfulness practice, have to say to those using mindfulness techniques to address the issues of chronic pain, stress, depression relapse and other disorders? This is not to suggest that patients need to be confronted with Buddhist teaching when engaging with these approaches. Common-sense suggests that that would often hinder more than it would help. Nonetheless, the insights contained in the Buddhist tradition – transposed into the clinical context – might help instructors in the Mindfulness-Based Approaches (MBAs) deepen their understandings of mindfulness and so enhance their teaching methods. The investigation that follows has offered me the opportunity to deepen my understanding of both of these traditions – one spiritual, the other clinical. It is my hope that it will be of some use to practitioners in both disciplines. Chapter One: Rationale and Methodology Aims of Chapter One This chapter begins with a brief statement of the research issue the study addresses. It goes on to outline the context from which I am undertaking the research and it lays out the rationale of the study in more detail, focusing on the specific questions asked. It then discusses the research tools used, focussing in particular on the question of literature research as a valid methodology. It describes the kind of evidence used in the study and concludes with a discussion of how the evidence gathered was analysed and processed. The Research Issue Evidence suggests that mindfulness-based clinical interventions are effective (Baer, 2003; Grossman et al. 2004; Segal et al. 2003; Ma and Teasdale, 2002), and Mindfulness-Based Approaches (MBAs) are currently being used in a wide variety of clinical contexts (Baer, 2003). But researchers in the field have only recently begun to operationalize the concept of mindfulness and to provide coherent definitions of it (Bishop et al., 2004). The aim of this study is to investigate whether the approach to mindfulness that is found in traditional Buddhist thought and practice has anything to offer the task of operationally defining mindfulness for clinical and clinical research purposes. In particular, this study focusses on the traditional Buddhist approach to mindfulness as a form of cognitive training, and it asks whether that aspect of mindfulness has been sufficiently acknowledged in the literature on MBAs to date. At first glance the overlap between Buddhism and MBAs may not be apparent. Mindfulness itself, however, is, in its origins, “distinctively and quintessentially Buddhist” (Gombrich, 1988, p.64). This study attempts to discover the extent to which certain key Buddhist ideas have come to inform MBAs and to ask whether there is anything more to be found in Buddhist thought and practice that might further enrich the clinical application of mindfulness. The Context and Background of the Research As a committed Buddhist, a meditator, writer and teacher of Buddhism and associated disciplines, I have more recently been training in the delivery of mindfulness-based stress reduction both with members of the Centre for Mindfulness Research and Practice that is part of the University of Wales, Bangor, and with Dr. John Teasdale, one of the co-founders of Mindfulness-Based Cognitive Therapy(MBCT), in Cambridge. In the course of this training I have come to notice more and more the considerable overlap between Buddhism and MBAs and also to begin to question whether there might be more in traditional Buddhism, both in terms of teaching and practices, than is currently acknowledged in the literature on MBAs or in their clinical applications. Kabat-Zinn, perhaps the most pre-eminent proponent of MBAs and one of the founders of the approach, clearly acknowledges the Buddhist contribution to the field, seeing the Buddha’s teachings as a coherent phenomenological description of the nature of mind, emotion, and suffering and its potential release, based on highly refined practices aimed at systematically training and cultivating various aspects of mind and heart via the faculty of mindful attention… (Kabat-Zinn, 2003, p. 145) But as I have progressed in my training in MBAs, certain questions have occurred to me again and again. Is there more to mindfulness than is explicitly acknowledged within MBAs? The Buddhist literature on mindfulness is rich and diverse. Could an investigation in this area, that focusses on discovering material that might have clinical application, uncover more than has thus far been used? Clearly, there are good grounds not to over-emphasise the Buddhist background to mindfulness within the context of MBAs. Especially in clinical contexts, the approaches need to be seen as secular and equally open to people of all religions or none. Thus, Kabat-Zinn (1991), while acknowledging the Buddhist background to mindfulness, stresses that it is a universal human faculty that can be practised apart from Buddhism or Oriental culture. Some authors take this further. The term “Buddhism”, for instance, doesn’t even occur in the index of Segal et al. (2002). This is not a problem, as such, and it would be a great shame if the potential clinical value of mindfulness was lost because of a misplaced over-emphasis on its religious origins. At the same time, it can be asked whether Buddhism, with its 2,500 year history of addressing the issue of human suffering, might have more to offer those engaged in the clinical endeavour to alleviate distress. Beginning to research this area, I came to realise that one aspect of Buddhist thought, at least, that seems not to be acknowledged in the literature on MBAs is the use of mindfulness meditation as an explicit form of cognitive training. This issue became the central focus of my research and it is around my findings in this area that this study is based. The Research Questions This Study Addresses The specific questions addressed in this study are as follows: First of all, What part does cognitive training play in the early Buddhist conception of mindfulness practice? Then, to see whether MBAs might be further enriched by the inclusion of concepts and practices from Buddhism, it asks How might the Buddhist approach to cognitive training further enrich our understanding of MBAs? This study may have several values – By making explicit the traditional relationship between mindfulness and cognitive training, the mechanisms whereby mindfulness produces beneficial change might be further illuminated for researchers and instructors in MBAs. There is still much discussion in the field of MBAs around the operational definition of the construct of mindfulness (Baer et al., 2004; Bishop, 2002; Bishop et al., 2003; Dimidjian and Linehan, 2003; etc.). An investigation into the Buddhist origins of the construct might usefully inform that discussion. By making explicit the relationship between Buddhism and MBAs, MBA instructors might gain a clearer understanding of the background to their approach. This enriched understanding might lead to a more deeply informed presentation of their material. As Teasdale et al. (2003) point out Within the tradition in which mindfulness training was developed, mindfulness was never seen as an end in itself, but as one part of a comprehensive, multifaceted path to resolve a clearly formulated problem. The same is likely to be true of effective clinical use of mindfulness training. (p.158) Anecdotal evidence suggests that there is an increasing interest in teaching MBAs at Buddhist centres in the West. In Britain and Ireland, for example a Google search, carried out on the 14th of August 2005, revealed that there are courses based on MBAs currently available at Buddhist centres in Dublin, Manchester, Edinburgh, Glasgow, Cambridge, Brighton and London. This study might help to clarify the approaches taken at such centres, delineating, for example, what might best be left in the territory of Buddhism and what might usefully be carried over into the domain of MBAs. Dimidjian and Linehan (2003) ask whether or not it might be clinically advantageous to include in MBA treatment programmes a more explicit discussion of the goals of mindfulness as practiced in a spiritual context and they wonder whether the clinical practice of mindfulness is diluted by a failure to discuss these issues explicitly. “… do clients receive a ‘watered down’ version of what they could receive if clinicians did not separate out these aspects?” (Dimidjian and Linehan, 2003, p.167). There are arguments to be made on both sides of this debate, and this study might usefully inform a discussion of the issue. Teachers in clinical settings may find their work enhanced and enriched by the inclusion of elements more explicitly drawn from the religious or spiritual dimension of mindfulness. Those teaching MBAs in Buddhist centres may be tempted to use the teaching as a vehicle for recruitment or proselytization. This study might usefully inform a discussion of the appropriate boundaries between the religious and the clinical aspects of mindfulness as it is taught in the context of MBAs. Methodology In the social sciences, two principal approaches to designing research are recognised: quantitative and qualitative. The former are intended to establish ‘objective’ evidence by gathering and analysing data that are measurable – by experimentation, for instance, or the statistical analysis of questionnaire results. The field of quantitative research in respect of MBAs grows almost daily. Grossman et al’s (2004) meta-analytic review of the field of mindfulness literature, for example, included 64 studies. This study, however, has a different concern. Its objects are theoretical. It deals with a comparison of concepts and, to a lesser extent, values, and as such it might be thought of as a form of qualitative research. McLeod’s (1994) description of qualitative research as a process of “systematic enquiry into the meanings which people employ to make sense of their experience and guide their actions” (p. 78) fits the approach taken here. But qualitative methodologies in general are aimed primarily at obtaining information from people, and that is not what this study sets out to do. Elias (2001) states that there are no published guidelines on research design and methodology for the kind of comparative study here proposed. Rather, he suggests, authors take their structure and style from similar studies. In support of this view, I have been unable to find specific references to the methodology and structure of a theoretical cross-disciplinary literature review such as this is. Cooper (1989); Wolcott (1991); Ely, M., et al. (2001); and Golden-Biddle, K & Locke, K., (1997); in their writings on the presentation of qualitative research include details of literature reviews, but these are specifically in support of field data and are not aimed at the critical or comparative analysis of the literature itself – especially as regards its theoretical content. This study is a form of literature research, and the approach taken is relatively simple. Once I had narrowed the focus of the study to the issue of mindfulness – as described in early Buddhist literature and in the literature on MBAs – as a means of cognitive training, the field of material available for comparison became manageable and relatively straightforward to cross-correlate. That said, it is important to acknowledge that such comparative studies have their limitations. The field of early Buddhist literature is large and there may well be texts that I have not consulted that would cast further light on the study. What is more, as a researcher I bring to my readings my own inevitable biases. Other might well make different interpretations. The Focus of this Study Any study concerned with investigating all the Buddhist methodologies for the alleviation of human suffering would run to many thousands of pages. The present study is necessarily more closely focussed. To begin with, I have chosen to restrict the study to issues arising out of a consideration of mindfulness, not some of the other methodologies that are commonly brought to bear in the Buddhist quest for awakening. As already noted, I began my research by looking into the parallels between Buddhism and MBAs. It soon became clear that there was a need to narrow the field and so I came to focus on early Buddhism, particularly the Pÿli material. Bishop et al.’s (2004) operational definition of mindfulness as used in clinical contexts provided a useful starting point. They see it as a process of regulating attention in order to bring a quality of nonelaborative awareness to current experience and a quality of relating to one’s experience within an orientation of curiosity, experiential openness, and acceptance. [It is] a process of gaining insight into the nature of one’s mind and the adoption of a de-centered perspective … on thoughts and feelings so that they can be experienced in terms of their subjectivity (versus their necessary validity) and transient nature (versus their permanence). (Bishop et. al., 2004, p.234) This is a rich definition, compacting much into few words, and it provided a list of qualities to investigate: mental elaboration, present moment awareness, curiosity, openness and acceptance, insight and the true nature of mind, decentring, subjectivity, and impermanence. It soon became clear that within a 20,000 word study one could never do justice to all of these concepts as they occur in the Pÿli literature and the study had to be focussed still further. One issue stood out. Investigating the issues of mental elaboration and present moment awareness in the Pÿli Buddhist literature, I began to see the extent to which that literature advocated mindfulness practice as an explicit form of cognitive training and I sought parallels to that in the literature on MBAs. That, then, became the focus of this study. Data Collection The question arises as to which Buddhist traditions and which corresponding elements of Buddhist literature one should draw upon. This study does not proceed from the presumption that any one part of the Buddhist canonical literature (Pÿli, Sanskrit, Chinese and Tibetan) is intrinsically more valuable than any other. Nor does it hold out for the value of one tradition over another – it does not presume that the Theravÿda is more valuable than Zen, or that the Tibetan Vajrayÿna is more valuable than the Chinese Pure Land approaches, for example. Nonetheless, out of this vast field of teaching, literature and tradition one must make choices, otherwise one might well be swamped in source literature. For that reason I have chosen to confine this study to early Buddhist literature and particularly to the Pÿli literature which, being the earliest surviving complete canon preserved in an Indian language, is in all likelihood nearest to some of what the historical Buddha himself might have taught (Sangharakshita, 1985). At the same time, it must be noted that since Buddhism was preserved as a strictly oral tradition for at least 200 years before the first texts were written down, the exact words of the Buddha himself have been irretrievably lost in the mists of time. In the past half century or so, particularly with the increasing recognition of the complex history of the early communities and texts, it has come to be widely agreed that nothing definitive can be known about the Buddha himself or the Buddhism he founded. (Ray, 1994, p. 9) In search of greater authenticity, I have chosen to rely primarily on canonical rather than secondary literature for most of my sources, although I have drawn at times on contemporary scholars of that literature and on the writings of contemporary Buddhist teachers of mindfulness. Having decided to focus the Buddhist aspect of my research in this way, the collection of relevant data became relatively simple. There are a small number of texts which have, between them, come to be regarded as the locus classicus of the Pÿli teachings on mindfulness (Sangharakshita, 1985). Going to these texts, as original (translated) source material, as well as to contemporary scholarly commentary upon them, and following ‘paper trails’ through references, footnotes and bibliographies, I was able to build up a picture of the early Buddhist attitude to mindfulness as a form of cognitive training. So far as the literature on MBAs is concerned, the field is smaller. In her meta-analytic study of the efficacy of mindfulness-based interventions, Baer (2003) focussed her attention on the 8 - 10 week Mindfulness-Based Stress Reduction (MBSR) programme as well as programmes using Mindfulness-Based Cognitive Therapy (MBCT). She decided not to use studies of the other MBAs she recognised – Dialectical Behaviour Therapy (DBT), Acceptance and Commitment Therapy (ACT), or Relapse Prevention (RP), all of which use mindfulness to one extent or another – because she found no studies that examined the mindfulness component of these independently of other behaviour change strategies they employed. For that same reason, this study is largely confined to an examination of mindfulness as a clinical intervention in the contexts of MBSR and MBCT. With this focus, the task became more manageable. The field of literature on MBAs although large, is at least digestible. There is a small handful of published books and the number of papers published in the journals of applied and theoretical psychology, behavioural and psychosomatic medicine, psychiatry, and allied disciplines, although growing almost by the day, is still small enough to become familiar with. Since almost all of this literature is now available on the Web in digital form, I downloaded most of the references I needed via the University of Bangor library website. Where I was not able to obtain an article by that means, the University of Cambridge library or the British Library inter-library loans service were able to provide copies. I have been fortunate to be guided in my reading of this literature by Rebecca Crane, Director of Training at the Centre for Mindfulness in the Institute of Medical and Social Care Research (IMSCaR) that is part of the University of Wales, Bangor. Ms. Crane is one of my two co-supervisors for this study. I was also aided by Judith Soulsby, the research officer at IMSCaR, whose familiarity with the published mindfulness research material was very helpful. I have been equally fortunate to be guided in my reading of the Pÿli literature by Dr. Robert Morrison, a scholar of that literature and my co-supervisor. What of the literature I don’t already own was easily obtainable from the Cambridge Buddhist Centre library or from the Web. In this way I was able to consult a number of dictionaries of Pÿli and Sanskrit, as well as books by contemporary scholars of Buddhism and teachers of mindfulness in the Buddhist context. Besides the Cambridge Buddhist Centre library, the library of the Western Buddhist Order in Birmingham has been a useful resource. Analysis of the Data Collected Focussing on the issue of mindfulness as a means of cognitive training, it became a relatively simple matter to see how the descriptions of mindfulness practice in the early Buddhist texts and in the literature on MBAs bore upon that theme. Mindfulness, in its clinical application, has begun to be operationally defined as a conceptual construct and the literature around the issue of definition is clear and not in need of a great deal of further analysis. It is, however, amenable to criticism, or at least to suggestion as to how it might be enriched, and that is a key aspect of this study. The task of understanding how the writers of the Pÿli literature understood mindfulness is more complex, for the texts require a certain amount of interpretation. In making such interpretations I have relied on a triangulation between the Pÿli texts themselves, the scholarly commentaries upon them, and my own lived experience of mindfulness. In doing this, I am aware of the prospect of subjective bias influencing my conclusions, but that must always be the case where an act of interpretation is called for. I can say, however, that in this process I was never aware of any significant tensions within the triangulation: there have been none of the dissonances that occur when an interpretation appears to be in some way forced. The final aspect of the task was cross-correlation. Having discovered what the early Buddhist literature and the literature on MBAs had to say of mindfulness as a means of cognitive training, the study then relates one to the other and draws its conclusions. Summary of Chapter One This chapter has outlined the rationale for this study and posed the research questions that it asks. It has delineated the focus of the study and described the research method, acknowledging its limitations. The study now goes on to present an overview of mindfulness itself, both from the perspective of MBAs and of early Buddhist thought. Chapter Two: Mindfulness in MBAs and Buddhism Aims of Chapter Two This chapter introduces the concept of mindfulness, firstly noting how it is considered in the context of MBAs and then in the context of early Buddhist thought. It notes the prospect of there being an overlap between early Buddhist thought and MBAs, both in terms of their common application of mindfulness to their endeavours and in their intent to address the issue of human suffering. What is Mindfulness from the Perspective of the Mindfulness-Based Approaches? At the outset, it is important to recognise that the term “mindfulness” may have different shades of meaning in Buddhism and MBAs. In the context of MBAs, Kabat-Zinn’s (1994) definition of mindfulness is widely used. He suggests it is a particular way of paying attention: on purpose, in the present moment, and nonjudgementally. (Kabat-Zinn, 1994 p.4) A search on scholar.google.com yields more than a dozen citations of this definition in scholarly journals. Crane (2004) describes mindfulness as simply being aware of what is going on, as it is arising, connecting deeply and directly with this and relating to it with acceptance; a powerful act of participatory observation. (Crane, 2004, p.2) Although acknowledging that the concept of mindfulness has its origins in Buddhism, Kabat-Zinn and other writers on MBAs maintain that its essence is universal (Kabat-Zinn, 2003; Grossman et al., 2004; Bishop et al., 2004). As a way of paying attention, says Kabat-Zinn (1991), it can be learned and practiced “without appealing to Oriental culture or Buddhist authority to enrich it or authenticate it” (p. 12). Although acknowledging that the construct of mindful awareness originated in earliest Buddhist documents, Grossman (2004), maintains that it is “neither religious nor esoteric in nature” (p.36). Rather, it may be seen as a form of naturalistic observation, or participant-observation, in which the objects of observation are the perceptible mental phenomena that normally arise during waking consciousness. (Grossman, 2004, p.36) This state of accepting, present-centred awareness, Kabat-Zinn (2003) asserts, is one which most people experience from time to time. We are all mindful to one degree or another, moment by moment. It is an inherent human capacity. (Kabat-Zinn, 2003, pp. 145 – 146) In the mindful state, we are fully and directly present to current experience, in a way that is unclouded by thought-based feelings or concepts about that experience (Crane, 2004). For many, though, life is lived habitually, within a fog of preconceived preoccupation. We may never be quite where we actually are, never quite touch the fullness of our possibilities. Instead we lock ourselves into a personal fiction that we already know who we are, that we know where we are and where we are going, that we know what is happening – all the while remaining enshrouded in thoughts fantasies and impulses, mostly about the past and about the future. (Kabat-Zinn, 1994, p. xv) There is a significant evolutionary advantage in being able to move our awareness into the future or the past. It is an important human skill. But it can become problematic to the point of pathology when it links in with two other human skills mentioned below. The first of these is sometimes referred to in the literature as “automatic pilot”. Teasdale et. al. (2000) use this notion to illustrate the distinction between mindfulness and mindlessness, referring to the common experience, when driving along a familiar route, of suddenly realizing that one has been doing so for miles “on automatic pilot,” unaware of the road or other vehicles, preoccupied with planning future activities or ruminating on a current concern. By contrast, “mindful” driving is associated with being fully present in each moment, consciously aware of sights, sounds, thoughts, and body sensations as they arise. When one is mindful, the mind responds afresh to the unique pattern of experience in each moment instead of reacting “mindlessly” to fragments of a total experience with old, relatively stereotyped, habitual patterns of mind. (Teasdale et al, 2000, p. 618) The second skill is “discrepancy monitoring”. … much of cognition occurs in the service of goals. We are constantly engaged in a process of comparing what is with what is desired, and much of our mental life and behavioral organization functions in the service of reducing any discrepancies …. When there is a discrepancy, negative affect occurs (e.g., fear, frustration) setting in motion cognitive and behavioral sequences in an attempt to move the current state of affairs closer to one’s goals, desires, and preferences …). If the discrepancy is reduced, then the mind can exit this mode and a feeling of well-being will follow until another discrepancy is detected, again setting this sequence in motion. (Bishop et al., 2004, p. 236) The ability to engage in complex activities, such as driving a car or operating a computer, without having to consciously think of what one is doing at each step, is a significant advantage. So is the ability to monitor discrepancies between how things currently are and how they might be. These three skills – the ability to dwell in the past or future, “automatic pilot” and discrepancy monitoring – can, however, come together pathologically. The processes of wishing to avoid unhappiness and to achieve happiness while constantly monitoring the discrepancy between how things are and how they should be or have been, when it is unconscious and on “automatic pilot”, can result in depressive rumination. These ruminations are patterns of thinking, feeling and behavior that are unhelpful because they simply circle round and round without producing a resolution. Ruminating about a problem feels as if it should bring a solution, … but such ruminations can often exacerbate the situation. (Segal et al., 2002, p. 158) “Why am I feeling this way? I am usually more cheerful than this. I shouldn’t be feeling this way.” Ruminations such as this can trap us into trying to deal with negative affect by using intellectual problem-solving techniques as if we were playing chess and might suddenly find the right move that wins us the game (Segal et al., 2002). It is as if we believe that our usual, clever, problem-solving abilities should be able to sort out all our problems. The feeling is very compelling and cannot be easily switched off. In fact, it is unlikely that persons would voluntarily give up their old ways of trying to deal with their problems by ruminating about them unless they had sampled another approach. (Segal et al., 2002, p.159) The analytical skills of problem solving, that are so useful in many areas of our lives, ironically can often increase our difficulties when brought to bear on the experience of mental or physical suffering (Crane, 2004). Mindfulness, on the other hand, confers upon one the skill of being able to disengage from such analytic thought processes and to bring one’s awareness back to the actuality of the present moment, creating an opening to the possibility of a wiser response to distress. The core aim of MBAs is to equip patients with ways of responding to stress, depression, or other problems, allowing them to step out of the mental reactions that often exacerbate their difficulties and interfere with effective problem solving. Mindfulness can enable one to see that the best way to achieve one’s goals might be to let go of the attempt to strive for results and instead begin to see and accept things just as they are, in the present (Crane, 2004). Grossman et. al., (2004, p. 36) suggest that the assumptions underlying MBAs are as follows: Humans are ordinarily largely unaware of their moment-to-moment experience, often operating in an ‘‘automatic pilot’’ mode. We are capable of developing the ability to sustain attention to mental content. Development of this ability is gradual, progressive and requires regular practice. Moment-to-moment awareness of experience will provide a richer and more vital sense of life, inasmuch as experience becomes more vivid and active mindful participation replaces unconscious reactiveness; Such persistent, nonevaluative observation of mental content will gradually give rise to greater veridicality of perceptions. Because more accurate perception of one’s own mental responses to external and internal stimuli is achieved, additional information is gathered that will enhance effective action in the world, and lead to a greater sense of control. We will return to consider some of the issues arising from this analysis in due course. For now, though, having provided an overview of mindfulness from the perspective of MBAs, let us briefly consider the Buddhist perspective. The Buddhist Perspective on Mindfulness In the context of Buddhism, the term “mindfulness” is generally taken to be a translation of the Pali sati which is the equivalent of the Sanskrit term smŒti. Rhys-Davids and Stede, (1993) in their Pali-English Dictionary link sati etymologically to the Vedic Sanskrit term smŒti, that connotes “memory” or “mental retention” (Monier-Williams, 1999). Indeed sati, in the sense of “memory”, occurs on several occasions in the Buddhist literature (Anÿlayo, 2003). Where the term is rendered as “mindfulness”, however, it is because the presence of sati enables one to remember “what is otherwise only too easily forgotten: the present moment” (Anÿlayo, 2003, p. 47 – 48). Sati represents the ability to simultaneously maintain in one’s mind the various elements and facets of a particular situation. This can be applied to both the function of memory and to awareness of the present moment. (Anÿlayo, 2003, p. 48 – 49) Mindfulness is valued in Buddhist thought as one of the chief means of making spiritual progress. Thus the Dhammapada, an early text revered in both the Pali and Sanskrit wings of the tradition (Sangharakshita, 2001) praises mindfulness as follows: 29. Mindful among the unmindful, wide awake among the sleeping, the man of good understanding forges ahead like a swift horse outdistancing a feeble hack. 30. By means of mindfulness Maghava … attained to the chieftaincy of the gods. Mindfulness is always praised, unmindfulness always despised. 31. The almsman who delights in mindfulness and who regards unmindfulness with fear advances like fire, burning up fetters gross and subtle. 32. the almsman who delights in mindfulness and who regards unmindfulness with fear is not liable to regression. He is in the presence of Nirvana. (Sangharakshita, 2001, pp. 20 – 21) The person who delights in mindfulness “is in the presence of Nirvana”. Nirvana is used here as a synonym for bodhi – “awakening” – the goal of the Buddhist spiritual life. From the Buddhist perspective, the vast majority of people are not “awake”. We have not realised our fullest potential and live our lives in a fog of delusion. And yet every one of us has the capacity to be clearer, wiser, happier, and freer. We have the capacity to penetrate directly to the heart of reality – to come to know things as they really are. (Kulananda, 2003, p.8) This penetration, to the very heart of reality, is what the Buddha termed “awakening”, and the Buddhist project, certainly in terms of the early tradition with which we are dealing, is to progress towards it by degrees. As the Buddha put it in the Pahÿrÿda Sutta (AÇguttara Nikÿya, ii.47), just as the ocean slopes gradually to the depths, so the approach to awakening is gradual and by increasing degrees. Following the path opened up by the Buddha, the mindful person – according to the Dhammapada quote above – “is not liable to regression”, but “forges ahead” towards awakening, “burning up” the fetters that bind him or her to the unawakened state. Here we see one of the chief distinctions between Buddhism and MBAs. MBAs seek to alleviate distress. The explicit goal of Buddhism is to eliminate it altogether. MBAs seek to alleviate suffering by training clients or patients in more skilful ways of “coping” with stress (Grossman et. al., 2003), “managing” chronic pain (Kabat-Zinn, 1991), “treating” depression relapse (Segal et al., 2002). The goal of Buddhism is more explicitly all-encompassing. The achievement of Awakening involves “the deepest understanding of the nature of suffering, its cause, its cessation, and the way leading to its cessation.” (Gethin, 1998, p.15) The early Buddhist texts “present the Buddha’s teaching as the solution to a problem.” (Gethin, 1998, p.59) The problem, “which is the fundamental problem of life” (Gethin, 1998, p.59), is termed dukkha in Pali, duåka in Sanskrit. Loy (2000) translates it helpfully as “lack”, a sense, he says, that emerges from our profound and repressed intuition that we are not real. our most troublesome repression is not sexual wishes, nor even death fears, but awareness of non-self – the intuition that ‘I am not real’ – which we become conscious of (the ‘return of the repressed’) as a sense of lack infecting our empty core. It is the deep feeling we all have that ‘something is wrong with me,’ that something is missing. (Loy, 2000, p.1) Most commonly, however, translators render the term as “suffering” and although that lacks the existential shades of meaning that Loy’s translation neatly highlights, it does account for the simpler sense of physical suffering that occurs when, for example, we cut ourselves or break a leg. Since these feelings, too, are spoken of as dukkha (Nyanatiloka, 1972), I will follow the convention for the time being in using the term “suffering”. The Buddha was quite explicit about the intent of his teaching: “… what I teach is suffering and the cessation of suffering.” (Majjhima Nikaya i 140) As he observed in his teaching of the Four Noble Truths, suffering is caused by thirst and his approach to the cessation of suffering was by way of the complete cessation of what is known in Pÿli as taÝhÿ. Literally ‘thirst’, it is a state of wanting, of unfulfilment, from the most primitive and crude depths to the most refined heights (Morrison, 1997). Best understood as a metaphor that attempts to capture the most pervasive affective characteristics of the unawakened state, it is “the source from which spring the various means of seeking some form of gratification and purpose in life” (Morrison, 1997, p. 148). Addressing his first monastic followers (bhikkhus) after his awakening, the Buddha put it like this (each verse will be interspersed with explanatory commentary): This, bhikkhus, is that middle way awakened to by the Tathÿgata, which gives rise to vision, which gives rise to knowledge, which leads to peace, to direct knowledge, to enlightenment, to NibbÿÝa. (Saçyutta Nikÿya, V. 56) Tathÿgata, “The One Who Have Thus Come” or “The One Who Has Thus Gone”, is a synonym for the Buddha. NibbÿÝa is the Pÿli equivalent of the Sanskrit Nirvana – a synonym for awakening. Now this, bhikkhus, is the noble truth of suffering: birth is suffering, aging is suffering, illness is suffering, death is suffering; union with what is displeasing is suffering; separation from what is pleasing is suffering; not to get what one wants is suffering; in brief, the five aggregates subject to clinging are suffering. (Saçyutta Nikÿya, V. 56) The “five aggregates” referred to above are the five aspects into which the Buddha summed up all the physical and mental phenomena of existence and which appear to the unawakened as their ego or personality (Nyanatiloka, 1972). These aspects are one’s physical body and its senses; feelings that are pleasant, unpleasant or neutral; ideas and concepts; desires and volitions; and self-consciousness (Gethin, 1998). That the five aggregates – all of unawakened human experience – are marked by suffering is the First Noble Truth. Now this, bhikkhus, is the noble truth of the origin of suffering: it is this thirst which leads to renewed existence, accompanied by delight and lust, seeking delight here and there; that is, thirst for sensual pleasures, thirst for existence, thirst for extermination. (Saçyutta Nikÿya, V. 56) Implicit in the phrase “renewed existence” is the Buddhist idea that all existence is contingent. In particular, the human personality or selfhood, constantly subject to change, is a deluded construct of the unawakened mind. As we have seen, the Buddha of the early texts spoke of the human personality as made of five aggregates, and each of these aggregates, he said, being subject constantly to change – and therefore having no fixed, enduring existence – should be apprehended with the clear understanding that “this is not mine, this I am not, this is not my self” (Majjhima Nikÿya, i. 138 –9). In other words, although we do experience, it is a mistake to infer, in a Cartesian sense, that because we experience we exist as fixed and separate selves. Our experience always comes down to one or another of the five aggregates: a specific sense datum, a feeling, an idea, a wish or desire, and a consciousness of one thing or another. Each of these is in a state of constant change. From one moment to the next, none remains for more than an instant. Apart from these experiences, one can never actually come upon or experience the “I” that is having the experience. How can we know it is there? We cannot conceive of consciousness apart from all of these changing details and “if we abstract all the particular details of consciousness we are not left with a constant, individual ‘self’ but a blank, a nothing.” (Gethin, 1998, p.138) As each of the aggregates changes so our existence is continuously renewed and the engine driving this process, the Buddha says, is thirst – driving us in constant quest for being and for non-being. When states are pleasant we wish them to continue. When they are unpleasant we wish them to be eliminated. This is the unawakened human condition: a constant vacillation between thirst and aversion – continuation and elimination. Thirst, says the Buddha in the Saçyutta Nikÿya, is the cause of suffering. This is the Second Noble Truth. Now this, bhikkhus, is the noble truth of the cessation of suffering: it is the remainderless fading away and cessation of that same thirst, the giving up and relinquishing of it, freedom from it, nonreliance on it. (Saçyutta Nikÿya, V. 56) The Third Noble Truth asserts that with the cessation of thirst, suffering, too, ceases. Now this, bhikkhus, is the noble truth of the way leading to the cessation of suffering: it is this Noble Eightfold Path… (Saçyutta Nikÿya, V. 56) The Fourth Noble Truth is that there is a path leading to the cessation of suffering. In this particular formulation, the path is spoken of as the Noble Eightfold Path, comprising right view, right understanding, right speech, right action, right livelihood, right effort, right mindfulness and right concentration. Although the explicit goal of Buddhism is the complete cessation of suffering, whereas for MBAs the goal is its amelioration, clearly there is the possibility of a considerable overlap between them, for what leads to the cessation of suffering might also, at an earlier stage of its practice, lead to its amelioration. Exactly what this overlap might be, how it might be understood, what its boundaries are, and whether it might be usefully extended, is the topic of this study itself. Summary of Chapter Two This chapter has reviewed how mindfulness is considered firstly in the context of MBAs and then in the context of early Buddhist thought. It has noted the different aims of both projects. MBAs seek to ameliorate suffering, Buddhism aims to eliminate it. But it has also noted the prospect of there being an overlap between early Buddhist thought and MBAs, both in terms of their common application of mindfulness to their endeavours and in terms of their intent to address the issue of human suffering. The next two chapters will review in more detail how mindfulness is conceived and applied, firstly in the context of MBAs and then in the context of early Buddhist thought. Chapter Three: The Application of Mindfulness in Clinical Contexts Aims of Chapter Three This chapter begins by providing a brief overview of the main Mindfulness-Based Approaches (MBAs). It then presents a brief review of some of the current research into Mindfulness-Based Stress Reduction (MBSR) and Mindfulness-Based Cognitive Therapy (MBCT). It goes on to consider mindfulness from a clinical perspective, and it discusses the possible mechanisms that might account for its effect in bringing about symptom reduction. It then introduces the mindfulness practices taught in clinical and other contexts, it notes how the style of teaching bears upon what is learned, and it describes the MBA’s approach to cognitive training. The Mindfulness-Based Approaches Much of the interest in the clinical applications of mindfulness emerged from the introduction of MBSR, a manualised treatment programme that developed in a behavioural medicine context for the management of chronic pain (Kabat-Zinn, 1982). The most frequently cited method of mindfulness training (Baer, 2003), MBSR is now widely used to treat the psychological effects associated with chronic illnesses as well as emotional and behavioural disorders (Kabat-Zinn, 1998). The Center for Mindfulness in Medicine, Health Care and Society (CFM), where MBSR began in 1979, had by 1999 delivered the programme to over 10,000 patients, and the teaching of MBSR has extended into prisons, poor inner-city areas, to groups such as medical students, as well as into corporate settings (Crane, 2004). As of 1999 there were 240 centres in the USA offering MBSR programmes (Baer, 2003). MBCT combines training in mindfulness meditation with cognitive therapy (Segal et al., 2002). A large multi-site randomised controlled trial has shown that this approach can significantly reduce the rate of relapse in recurrent major depression (Teasdale et al., 2000). The UK’s National Institute for Clinical Excellence (NICE) currently recommends that MBCT be considered for people who are currently well but have experienced three or more previous episodes of depression, because this may significantly reduce the likelihood of future relapse. (NICE, 2004, p.35) Recent innovations in psychological treatment have also led to an increase in the use of mindfulness-based approaches. Dialectical Behaviour Therapy (DBT) (Linehan, 1993a), has been shown to reduce self-mutilation and suicidal behaviour in chronically suicidal patients with borderline personality disorder (Linehan et al., 1991). DBT uses a training in mindfulness meditation to foster improvements in affect tolerance. Besides these, MBAs are used in the treatment of a wide range of clinical syndromes, including generalized anxiety disorder, post-traumatic stress disorder, substance abuse and eating disorders (Bishop et al., 2004). All of these approaches involve a rigorous programme of training in meditation, aimed at developing the capacity to apply mindfulness to one’s experience in order to enhance emotional well-being and mental health. MBAs are not considered relaxation or mood management techniques. Rather, they are a form of mental training to reduce cognitive vulnerability to reactive modes of mind that might otherwise heighten stress and emotional distress or that may otherwise perpetuate psychopathology. (Bishop et al., 2004, p. 231) As noted in the Introduction, this study focusses in particular on the application of mindfulness in the contexts of MBSR and MBCT. In both of these programmes three main practices are taught: sitting meditation, body scan, and mindful movement. In all of these, participants are instructed to focus their attention on an object of observation, such as the breath, or the detailed sensations involved in walking, or a hatha yoga posture, and to be aware of it in each moment. When thoughts, feelings or sensations arise, the instruction is, as best one can, simply to observe them with a kindly, non-judgmental curiosity; and when one notices that the mind has wandered into thoughts, memories, or fantasies, their nature or content is briefly noted, if possible, and one’s attention is then returned to the object of observation (Baer, 2003). An important consequence of this is the realization that sensations, thoughts, and feelings fluctuate, are transient, and do not finally define the individual. The difficult and painful therefore become more manageable (Kabat-Zinn, 1991). … when you identify with your thoughts or feelings or with the sensations in your body … there is much greater turmoil and suffering than when you dwell at the non-judgmental observer of it all, identifying with the knower, with awareness itself… If you are not your body, then you cannot possibly be your body’s pain. (Kabat-Zinn, 1991, pp. 297 – 298) For those participants prone to depression, mindfulness develops a person’s ability to be attentive to and aware of their negative thoughts, but not to react to them. The idea is to change a person’s relationship to their negative thoughts, rather than the content of their thoughts. (NICE, 2004, p. 62) The Current Research Basis of MBSR and MBCT MBSR, which has now been clinically used and researched for more than thirty years, is considered to be a main-stream psycho-social treatment in the USA, where it has entered the medical school curriculum (Crane, 2004). Research on it to date has described and investigated its effects – rather than investigating the mechanisms by which it acts or analysing its particular effects on specific diagnostic areas. Kabat-Zinn and his colleagues have been largely responsible for the growing research into the effects of MBSR, from the 1990’s to date, although the field is rapidly growing (Crane, 2004). There have been investigations into the effects of MBSR in treating chronic pain (Kabat-Zinn et al., 1987); anxiety and panic disorders (Kabat-Zinn et al., 1992; Miller et al., 1995); psoriasis (Kabat-Zinn et al., 1998); and fibromyalgia (Kaplan et al., 1993). All of these studies showed significant overall improvement in patients’ physical and psychological states. Since then, the application of MBSR has broadened, and there has been research into its use in a range of settings, including cancer patients (Carlson et al., 2003; Saxe et al., 2001; Tiefenthaler et al., 2002) as well as with currently healthy student and general populations (Reibel et al., 2001; Astin, 1997; Shapiro et al., 1998; Rosenweig et al., 2003). Davidson et al. (2003) showed that the delivery of MBSR to a population of employees in a company has the effect of increasing left sided brain activation, associated with positive forms of emotional expression and dispositional emotional expression, as well as a greater rise in antibody titers. Baer (2003) suggests that the current evidence base for MBSR is compelling, but she notes that there are methodological flaws and evidence gaps at this stage of the investigation. Only large scale sound research in the future will be able to bridge this schism between methodological deficiencies, on the one hand, and the potential promises of mindfulness training, on the other, as consistently revealed by a number of positive studies. (Baer, 2003, p.14) MBCT, a development of the MBSR programme, using the same meditation structure and practices, is a group-based intervention designed specifically to train recovered recurrently depressed patients to disengage from depressogenic thought patterns that are believed to play a significant part in mediating depression relapse (Ma, Teasdale, 2002). Although MBCT may have the potential to benefit people with other diagnoses, the developers explicit intention is that it be used in targeted ways with groups of individuals sharing the same problem focus (Teasdale et al., 2003). A large multi-site Randomised Controlled Trial (RCT) of MBCT demonstrated statistically significant effects in reducing depression relapse over the twelve month period following the intervention (Teasdale et al., 2000). A further RCT (Ma, Teasdale, 2002) replicated the findings of the previous trial, finding that In a group of recovered recurrently depressed patients with three or more episodes of major depression, MBCT more than halved relapse/recurrence rates compared to patients who continued treatment as usual. (Ma, Teasdale, 2002, p.24) Both RCTs found that there was no evidence of benefit to patients with two previous episodes of depression. Investigating this differential, Ma and Teasdale (2002) noted that the group with two episodes of depression had a normal experience of childhood followed by difficult life events giving rise to depressive episodes. The group with three or more episodes had a difficult experience of childhood and an earlier onset of depression. They concluded that MBCT is most likely to be effective in preventing relapse that is unrelated to current major life difficulty. Soulsby et al. (2002) have studied the effects of MBCT in a generic mental health setting; Roberts and Surawy (2002) have studied its effectiveness as a group treatment for those with Chronic Fatigue Syndrome (CFS); and Bartley and Soulsby (2003) are currently investigating the effects of MBCT with patients who have an oncology diagnosis and their carers. Research into the effects of MBCT, apart from its application to depression relapse, is still in the early stages. How Mindfulness May Help in the Clinical Context Baer (2003) suggests five mechanisms that may explain how mindfulness skills can lead to symptom reduction and behavioural change. These are: Exposure: Clients come to experience pain or other forms of suffering without excessive reactivity, thus becoming more tolerant of difficulty and distress, both physical and mental (Teasdale, 1999). The meditation practices used in MBSR often include extended periods of motionless sitting. This can lead to pain in muscles and joints, and MBSR instructors often encourage students first of all to open up to the experience of pain or discomfort and then consciously to choose an appropriate response to that, knowing that there are choices other than the immediate instinct to react with various cognitions (‘this is unbearable’) emotions (anxiety, anger), and urges (to shift position) that often accompany pain sensations. The ability to observe pain sensations nonjudgmentally is believed to reduce the distress associated with pain. (Baer, 2003, p.128) The application of this strategy by chronic pain patients may serve several functions. Prolonged exposure to the sensations of chronic pain, without catastrophic consequences, might lead to desensitisation and a consequent reduction in the emotional responses elicited by the pain. In this way, the practice of mindfulness could lead to the ability to experience pain without excessive emotional reactivity. It can also help participants to see their own emotional reactivity more clearly – noticing that it is something ‘extra’ that they add to the initial experience and that it is possible to have a difficult experience and choose to respond differently. Even if the pain sensations themselves are not reduced, suffering and distress might thus be alleviated (Kabat-Zinn, 1982). A similar mechanism applies to the potential effects of mindfulness training on anxiety and panic (Kabat-Zinn et al., 1992). The sustained, non-judgemental observation of anxiety-related sensations, that does not attempt to escape, suppress or otherwise avoid them, can lead to a reduction in the emotional reactivity typically brought about by anxiety symptoms. Self-Management: Self-observation resulting from mindfulness training may promote the use of a range of coping skills. For example, Kabat-Zinn (1982) suggests that increased awareness of pain sensations and stress responses as they occur might allow individuals to bring to bear a variety of coping responses, including skills acquired apart from the MBSR programme. Teasdale et al. (1995) note that mindfulness training encourages awareness of all cognitive and emotional events as they occur. Since this includes those that may be early signs of potential depressive relapse, they may promote the recognition of early signs of a problem precisely when the application of previously learned skills will most likely be effective in preventing it. Linehan (1993b) suggests that by learning to focus “onemindfully” on the present moment, individuals who have difficulty completing important tasks because they are distracted by worries, memories, or negative moods develop the useful skill of attention control. Relaxation: Although not explicitly a goal of mindfulness training, evidence suggests that physical relaxation is a common consequence of it (Kabat-Zinn, 1991). Kabat-Zinn et al., (1998) suggest that MBSR may be applicable to stress-related medical disorders, such as psoriasis. They note that meditation can induce relaxation, which may contribute to the management of such disorders. But the general aim of mindfulness training is not to produce relaxation. Indeed, the non-judgmental observation of current conditions that mindfulness training seeks to produce might include “autonomic arousal, racing thoughts, muscle tension, and other phenomena incompatible with relaxation.” (Baer, 2003 p.130) Acceptance: By learning to ‘open to the difficult’ clients, especially those suffering from aversive reactions to chronic conditions, can learn that although their condition may not change, their approach to it may, and this can lead to a significant reduction in the symptoms exhibited (Kabat-Zinn, 1991). All of the treatment programmes that Baer (2003) reviewed included the acceptance of pain, thoughts, feelings, urges, or other bodily, cognitive, and emotional phenomena, without trying to change, escape or avoid them. “Acceptance is so important because its opposite is too risky” (Segal et al., 2002, p.223). An unwillingness to accept negative thoughts, feelings or physical sensations can be the first step in a chain of mental events that can lead very quickly to the reinstatement of automatic, habitual, relapse-related patterns of mind. Our usual tendency in relation to thoughts, feelings or bodily sensations is to try to hold on to those we like and push away those we don’t like. Each of these responses is the opposite of acceptance (Segal et al., 2002). Mindfulness, by contrast, allows us to open to the difficult in a more accepting way. One way to relate skilfully to unpleasant experiences is to register that they are here, and to allow them to be as they are, in this moment, and simply to hold them in awareness. Responding in this way, described as ‘allowing,’ ‘letting be,’ or ‘holding in awareness,’ conveys the core theme of acceptance toward difficult feeling states. This is in contrast to automatically reacting to these thoughts or emotions. (Segal et al., 2002, p. 225) Cognitive Change: The theme of mindfulness training as an explicit means of bringing about cognitive change is the core issue of this study. Several of the authors that Baer (2003) studied noted that the practise of mindfulness could lead to changes in thought patterns, or in attitudes about one’s thoughts. The key idea here, from the perspective of MBAs, is that by developing a mindful perspective on them, clients learn the ability to see their thoughts just as thoughts, rather than them being a reflection of reality or truth. This leads to reduced reactivity (Teasdale, 1999) thus alleviating suffering and distress. It is remarkable how liberating it feels to be able to see that your thoughts are just thoughts, and that they are not ‘you’ or ‘reality’ … the simple act of recognizing your thoughts as thoughts can free you from the distorted reality they often create and allow for more clear-sightedness and a greater sense of manageability in your life. (Kabat-Zinn, 1991, p. 69 - 70) In their discussion of MBCT, Segal et al. (2002) suggest that a non-judgemental, decentred view of one’s thoughts, brought about by mindfulness training, may interfere with the ruminative patterns of thought that are characteristic of depressive episodes. Formerly depressed individuals may come to notice the onset of depressive thoughts and redirect their attention to other aspects of the present moment, such as breathing, walking, or sounds in the environment, so avoiding rumination. Teasdale (1999) describes this perspective on one’s thoughts as a “metacognitive insight.” To illustrate the specific meaning of the term ‘insight’ here, Teasdale provides an illustration: A recovered depressed patient attending a relapse prevention programme developed the liberating metacognitive insight “thoughts aren’t fact”. When she excitedly shared this insight with her husband, he responded “I was born knowing that”. (Teasdale, 1999, p. 146) Clearly, the metacognitive knowledge that thoughts are not facts is commonplace. And yet, in that form, it had had little ‘saving’ power in protecting her from the effects of depressive thought patterns. But the metacognitive insight acquired in the relapse prevention programme was one of the most important outcomes contributing to the preventative effects of the relapse prevention programme (Teasdale, 1999) To further illustrate this point, Teasdale (1999) uses a traditional Sufi teaching story: Uwais was asked “How do you feel?” He replied “Like one who has risen in the morning and does not know whether he will be dead in the evening”. His questioner responded “But this is the situation of all men”. Uwais replied “Yes, but how many of them feel it”. (Shah, 1974, p. 122) There is a significant difference between the factual knowledge that we all may die at any time and the direct, experiential awareness, from one moment to the next, of that fact. The former is simply information whereas the latter can have profound effects on our view of everything, radically affecting the way we live from moment to moment. In the context of mindfulness meditation practice, the ability to relate to thoughts simply as events in the mind (in other words, with metacognitive insight) is facilitated by designating another focus of attention – such as the breath, body or sounds – against which the experience of thoughts can be registered as simply another event to be aware of rather than as the primary ‘stuff’ of the mind or the self (Teasdale, 1999). The perspective of metacognitive insight with respect to thoughts is further enhanced by the instruction to note the content of thoughts as they arise and then to let go of them and return to the primary focus of attention. The breath or other non-thought focus then serves as an ‘anchor’ returning awareness to the present moment and limiting the extent to which it becomes lost in the apparent reality created by familiar thought streams. By helping patients to recognize recurring patterns in thought content, mindful observation of thoughts also helps them to see such thoughts as patterns of the mind rather than “as necessarily valid readouts on reality.” (Teasdale, 1999, p.154) The mode of mind characterized by mindfulness and metacognitive insight has been popularly characterized as one of ‘being’, in contrast to the more usual ‘doing’ modes that make up so much of our lives and which, when distorted, can lock us into dysfunctional emotional states. The doing mode “is goal orientated, motivated to reduce the gap between how things are and how we would like them to be…” (Segal et al., 2002, p.73). The being mode, on the other hand, is not motivated to achieve goals and does not monitor current experience in the same evaluative manner. The full richness of this mode, however, “is not easily conveyed in words – its flavor is best appreciated directly, experientially” (Segal et al., 2002, p.73). Extended mindfulness practise with the thoughts, feelings and bodily sensations that occur in the non-depressed state gives recovered depressed participants the skills to enter the ‘being’ mode. This prepares them to use such skills at times of potential relapse, thus pre-empting the establishment of the pattern of ruminative thought and so reducing the risk of relapse and recurrence of depression (Teasdale, 1999). Teasdale et al. (1995) note one other practical advantage of mindfulness skills in encouraging cognitive change. They can be practiced during periods of remission, when depressogenic thinking may be occurring too rarely to allow the regular practice of traditional cognitive therapy exercises, such as identification and disputing of cognitive distortions. The Structure of a Mindfulness Course and a Review of the Practices Used As has already been mentioned, for the purposes of this study, I am mainly concerned with mindfulness as it is taught in the context of MBSR and MBCT. MBCT, as taught for the purpose of preventing depression relapse, is a highly manualised intervention (Segal et al., 2002). But as we have seen it is also used as an intervention with chronic fatigue, cancer, stress and other disorders. The founders of approach are concerned that each of these interventions should have its own specific problem focus (Teasdale et al., 2003), which would involve tailoring the programme to suit the participant group involved. MBSR, as we have also seen, is similarly delivered in a wide variety of settings to address a diverse set of problems: stress, chronic pain, fibromyalgia, psoriasis, recidivism and so on. Unlike MBCT, it is usually delivered generically to mixed diagnosis groups (Kabat-Zinn, 1992). Despite the differences of focus that each of these separate programmes might involve there is a broad congruity between them in respect of the mindfulness practices they employ. Each of them, over the course of 8 or 10 weeks (Baer, 2003) will use a similar form of mindfulness meditation sitting practice, “body scan”, and some form of mindful movement – usually yoga, t’ai chi, or qi-gong, and each will prescribe “homepractice” of up to an hour a day for at least 6 of the 7 days of each week of the course (Crane, 2004). A Typical Mindfulness Course As noted above, courses will vary to some extent according to the specific problem they seek to address, and MBCT differs, in part, from MBSR. Nonetheless, the course described below is more or less generic and the basic elements described are – except where otherwise noted – found in both approaches (Kabat-Zinn, 1992; Segal et al., 2002; Crane, 2004). A typical course might span 10 sessions, comprising an introductory evening, eight weeks of instruction, and a follow-up session one month later. Sessions last between 2 and 3 hours. A typical course might comprise 10 to 20 first-time participants, 2 experienced “helper” participants (who set the room up, perform reception duties and so on) and 2 instructors. Participants are given handouts each week that detail homepractice for that week and review what they have learned in the class. They are also given tapes or CDs to guide them in their homepractice. The ‘raisin exercise’: This is usually the first mindfulness practice used on MBSR and MBCT courses (Kabat-Zinn, 1991; Segal et al., 2002). The instructors go around the class, handing out two or three raisins to each participant who are instructed to imagine that they have just dropped in from Mars and have never seen anything like these object before (Teasdale et al., 2002). Participants are then invited to examine one of these “objects” in much more detail. Picking it up, exploring its tactile qualities, examining its appearance, smelling it, slowly bringing it to their mouth, seeing how their hand and arm knows just where to put it, noticing, perhaps, their mouth watering. Then placing it in their mouth, feeling it on their tongue, exploring the sensation of having it in their mouth, and then taking a single bite. Noticing the sensations released, and then slowly (very slowly) chewing and finally swallowing. For many, this is their first experience of mindfulness. In particular, they come to notice the difference between automatically and unthinkingly eating handfuls of raisins at a time, barely noticing them, and the experience of eating just one raisin mindfully. Although responses to this will vary (some like it, others do not) the general point is made that most of the time we live our lives “on ‘automatic pilot,’ functioning mechanically, without being fully aware of what we are doing or experiencing. … as if we’re only half awake” (Kabat-Zinn, 1991, p. 21). For participants liable to depression the basic take-home message from [this] exercise is that we’re not aware of what’s going on a lot of the time… Missing out on the good means that life is not as rich as it might be. Not being aware of the bad means that we’re not in a position to actually take skillful action ourselves. Depression can creep up on us when our minds are elsewhere. (Segal et al., 2002, p. 109) For those who experience pain or stress, the prevalence of ‘automatic pilot’ means that there is less choice not to react. Automatic reactions, triggered out of unawareness, usually compound and exacerbate stress, making what might have remained basically simple problems into worse ones. (Kabat-Zinn, 1991, p. 248) The body-scan meditation: The next practice participants encounter is spoken of as “the body scan”. In this practice, participants typically lie on their backs with their eyes closed and are then instructed to direct their attention to different parts of the body in turn, experiencing whatever sensations, or none, there may be in that location. Because of the thorough and minute focus on the body in body scanning, it is an effective technique for developing both concentration and flexibility of attention simultaneously. (Kabat-Zinn, 1991, p.76 - 77) The ability to take one’s attention into the body, in detail, is a core skill in MBAs. What happens in the body importantly affects what happens in the mind. Feedback on the how the body feels is often an integral part of the loops that sustain old habits of thinking and feeling. (Segal et al., 2002, p. 110) A useful alternative to thinking about troubling thoughts or emotions is to bring awareness to how they manifest “as physical sensations or felt senses in the body” (Teasdale et al., 2002, p.110). In the case of chronic pain, participants learn the skill of non-reactively being with, and letting go of, intense sensation. If their pain is in their lower back, for instance, you dwell there, breathing, until you are ready to let go of the lower back on purpose and move the focus of your attention to the upper back and the chest. In this way you are practising moving through the region of maximum intensity… You allow yourself to be open to all the sensations there may be there, in all their intensity, watching them, breathing with them, and letting them go as you move on. (Kabat-Zinn, 1991, p.87) Sitting meditation: As the course unfolds, participants are systematically introduced to different elements of mindfulness meditation. Starting by learning to focus their attention on the breath for about ten minutes in week 2, in subsequent weeks they learn to broaden out that awareness to include a sense of the body as a whole, then sounds in their environment and from their own bodies, then thoughts, and finally they learn to sit with a “choiceless awareness” – simply being aware of whatever is predominant in their experience at any moment. By session 6, their homepractice is to follow that sequence – mindfulness of the breath, mindfulness of the breath and body, mindfulness of sounds and thoughts, and choiceless awareness – over a continuous 40 minute session of meditation. Participants are instructed, as best they can, to keep their attention on the object in question (the breath, breath and body, sounds or thoughts) and when they notice that their mind has wandered to notice where it has gone and then, with a gentle, kindly and curious attitude, return it to the object of attention. An essential characteristic of this practice is that the aim is not really to prevent the mind wandering, but to become more intimate with how one’s mind behaves. … A common instruction one hears is ‘If your mind wanders a hundred times, bring it back a hundred times.’ … The task is to accept those times when our mind has wondered and gently reconnect with our breathing. This allows us to sidestep the judgements and criticisms that may arise from believing we are failing… (Segal et al., 2002, p. 168). This develops patience and the capacity to be non-judgemental (Kabat-Zinn, 1991). It also trains the mind “to be less reactive and more stable.” (Kabat-Zinn, 1991, p. 65) Mindful movement: As noted above, the mindful movement sequences taught on MBSR and MBCT courses might include elements drawn from the Indian yoga tradition or from t’ai chi or qi-gong. Besides helping participants to become more mindful of their bodies by noting their changing physical sensations as they hold and change postures, the instructions given encourage participants to find their physical “edge” the point where a stretch, for example, can become uncomfortable (but not too uncomfortable) and the urge would be to pull-back into a more comfortable posture. The point is to move into and back from the point at which one is aware of these strong sensations, while keeping attention on these sensations as best one can. … The skill built in doing this with physical sensations comes into play later in the program, when a similar approach is used for mindfully moving into and out of painful emotions. (Segal et al., 2002, p. 178) This also helps participants, especially those with chronic pain, to discover that “the boundaries of how far your body can stretch and or how long you hold a position are not fixed and static” (Kabat-Zinn, 1991, p.98) and this can be a means of developing a moment-by moment “openness and responsiveness to their experience rather than remaining fixed in preconceptions of what may be possible in any moment” (Crane, 2004, p.37). Mindful walking: Walking meditation is a traditional Buddhist practice, taking the everyday activity of walking and using it as a mindfulness practice to become more aware of bodily sensations. We walk, knowing that we are walking, feeling the walking. (Segal et al., 2002, p. 178) Quite simply, the instruction is to walk. Initially very slowly, as best one can being mindful of all the many different bodily sensations involved in the process. Three-Minute Breathing Space: This mini-meditation, which evolved out of the MBCT programme (Crane, 2004), and is not generally found in MBSR, is intended to help participants bring their formal practice into daily life. There are three steps to the process, neatly summarised by Crane (2004): i) Step out of automatic pilot, recognise and acknowledge one’s current experience; ii) Bring attention to the breath; iii) Expand the attention using the sense of the breath and the body as a whole as an anchor, while opening to the range of experience being perceived. (Crane, 2004, p. 38 – 39) Participants learn over the weeks of the course to use the breathing space as a way of reconnecting with a more resourceful state of mind whenever things begin to get difficult for them. At such times it can “help ‘shift mental gears’ and connect with experience in the present moment” (Segal et al., 2002, p. 210). The Mindful Didactic Style When Segal et al. first visited the University of Massachusetts Medical Center to observe the work of Kabat-Zinn and his colleagues, they noticed that the MBSR instructors were themselves all practising mindfulness meditation and seemed able to embody the same gentle approach to patients’ difficulties that the patients themselves were being encouraged to take. This stance was itself highly ‘invitational’ and allowed patients to adopt a more ‘welcoming’, less ‘need to solve’, attitude to their difficulties (Segal et al., 2002). The commonality of experience between patients and instructors, in that both groups were working with the same meditation practices, allowed for a kind of continuity between their experiences — If class members described becoming aware of how they had been criticizing themselves, for example, the experience of dealing with self-critical thoughts was something the instructor had in common with other members of the class. The assumption here was simple: that minds tend to operate in similar ways and there is no basis for discriminating between the minds of those seeking help and those offering it. (Segal et al., 2002, p. 55 - 56) Because of their own practice of meditation, MBSR instructors embodied a particular relationship to the distress and emotion in their patients. (Segal et al., 2002). What MBAs instructors convey in their classes is not only instruction in technique. A vital part of it comes from their own embodiment of mindfulness in interaction with the class. Participants in the MBSR program learn about mindfulness in two ways: through their own practice, and when the instructor him- or herself is able to embody it in the way issues are dealt with in the class. … Just as in rock climbing, those who are learning need to feel that the instructor has both the skill and experience to deal with the difficult situations that will arise. In the same way mindfulness training involves the instructor participating alongside the patient, not giving instructions, as it were, from the bottom of the rock face. (Segal et al., 2002 p. 56 - 57) The MBAs approach runs counter to a commonly held, but mistaken, view that mindfulness is a way to escape or shut out unwanted thoughts and feelings. MBAs instructors instead try to show patients that fighting against unwanted thoughts, feelings and bodily sensations sometimes creates yet more tension and inner turmoil. With time, some of the tension itself can be reduced. Instead of continuously ‘feeding’ tension by participating in what their thoughts or feelings demand, participants stay close to this mental struggle “by finding a calm place from which to observe it.” (Segal et al., 2003 p. 60) One of the mindfulness instructor’s tasks is to embody that mindful, accepting, calm. The didactic style adopted within MBAs consciously sets out to empower participants by using their described experience of the practices as the vehicle for teaching. Embodying mindfulness themselves and encouraging an attitude of openness and curiosity, instructors work on the “assumption that participants are the ‘experts’ on themselves, with a fund of relevant experience and skills already” (Segal et al., 2002, p. 92). Thus, after each practice feedback is always invited and this becomes the main vehicle for teaching. In this way, all the elements in the curriculum are delivered in a manner which is woven into the actual experiences the participants (Segal et al., 2002). Cognitive Training in MBAs As noted above, Baer (2003) recognises that cognitive change is a significant factor in bringing about symptom reduction and behavioural change in participants on MBAs courses. In particular, participants learn to relate to thoughts simply as events in the mind, rather than the primary ‘stuff’ of the mind or the self. There are two primary ways in which MBAs seek to bring this realisation about. Firstly by designating another focus of attention, such as the breath, body or sounds, and instructing the participant to see thoughts in the same way as, for example, sounds. Thus, Segal et al. (2002) suggest the following meditation instruction: Just as with sounds, you focused awareness on whatever sounds arose, noticing them arise, develop and pass away, so now … bring awareness to thoughts that arise in the mind in just the same way – noticing when thoughts arise, focusing awareness on them as they pass through the space of the mind and eventually disappear. … Just let them arise naturally, in the same way that you related to sounds arising and passing away. (p. 196) Then, this perspective is further enhanced by the meditation instruction, used throughout the course, to note the content of thoughts as they arise and then to let go of them and return to the primary focus of attention (Teasdale, 1999) – the breath, body, or sounds. These two approaches to cognitive training in the context of MBAs are relatively explicit. There is also an implicit approach. As shown above, the attitude that mindfulness instructors bring to the courses significantly effect what participants learn (Segal et al., 2002). By embodying a calm, open, curious and accepting attitude to whatever arises in the class, instructors show the participants that such approaches to their own difficulties are indeed possible, and this is a vital element in how they come to cognise –and re-cognise – them over the period of the course. Summary of Chapter Three: This chapter has briefly outlined the main MBAs and reviewed some of the current research into MBSR and MBCT. It has noted that mindfulness may have its clinical effects by five means: Exposure: by creating a context that allows clients to experience pain and other forms of distress without undue reactivity, they become more tolerant of difficulty. Self-management: by learning to become more aware of cognitive and emotional events as they occur clients may be better prepared to bring coping skills to bear when they are needed. Relaxation: which is not an explicit goal of mindfulness training but is often an indirect consequence of it. Acceptance: learning to let go of aversive reactions that might worsen their condition. Cognitive change: especially the ability to see thoughts just as thoughts rather than as reflections of reality or truth. The chapter examined the principle practices used in MBAs: the ‘raisin exercise’, body scan meditation, sitting meditation and mindful movement, drawing out key elements in the cultivation of mindfulness in each case; and it discussed the mindful, acceptant attitude that MBA instructors are called upon to embody and drawn attention to the didactic style of MBAs. It showed that there are both explicit and implicit elements to the way in which cognitive training takes place on MBA courses, and it introduced an operational definition of mindfulness, suggesting that this might be further enriched by a consideration of the early Buddhist attitude to mindfulness in theory and practice. The next chapter will show how early Buddhism originally treated some of the key ideas now being used by contemporary clinicians and researchers. Chapter Four: Mindfulness in Early Buddhist Thought Aims of Chapter Four This chapter investigates mindfulness in early Buddhist thought. In particular, it shows that mindfulness in that context was conceived as a method of cognitive training aimed at bringing about a change in the way in which the world is perceived. The chapter begins by investigating the issue of mental elaboration, that is central to Mindfulness-Based Approaches (MBAs), as it was considered in early Buddhism. It then goes on to examine the issue of present moment awareness in early Buddhist thought and practice, focusing in particular on the Buddha’s discourse on the Four Foundations of Mindfulness. In conclusion, it notes that the early Buddhist approach to mindfulness focuses to a considerable degree on the issue of cognitive training, especially by way of training one’s apperceptions. The consequence, so far as early Buddhist thought is concerned, of training one’s apperceptions in this way is that one can thereby come, in time, to ‘see things as they really are’. Mindfulness and Mental Elaboration In their operational definition of mindfulness as used in clinical contexts, Bishop et al. (2004) suggest that it is a state of “non-elaborative awareness”. The Pÿli term for “mental elaboration” is papañca (pronounced papancha). Considered etymologically, this term conveys meanings such as ‘spreading out’, ‘expansion’, ‘diffuseness’ and ‘manifoldness’ (Ñÿnananda, 1997). Papañca should be understood, in the early Buddhist context, in contradistinction to two other terms: vitakka, “the onset or initial application of thought” (Ñÿnananda, 1997, p. 4) and vicÿra, “investigation and deliberation” (Ñÿnananda, 1997, p. 4). In contrast to vitakka and vicÿra – which between them constitute what we might call the creative use of thought and concepts – papañca hints at “the tendency for the worldling’s imagination to break loose and run riot.” (Ñÿnananda, 1997, p. 4). If the former, at least relatively, denotes cosmos in the mental realm, papañca seems to signify chaos … [it] tends to obscure the true state of affairs inasmuch as it is an unwarranted deviation giving rise to obsession. (Ñÿnananda, 1997, p. 5) From the perspective of MBAs, the term papañca encompasses the processes of ruminative thought characteristic of depression (Segal et al., 2002) as well as the style of thinking that Kabat-Zinn (1991) describes as “catastrophising”. … the “it’s me, it’s going to last forever, it’s going to affect everything I do” pattern. (p. 200) From the early Buddhist perspective, papañca includes the whole range of mental processes – thoughts, fantasies, obsessions – that keep us apart from an awareness of present-moment reality. How, according to early Buddhism, does papañca arise? The locus classicus for this is the Buddha’s ‘Discourse on the Honeyball’ (Madhupiݟika Sutta) –- Dependent on the eye and visual forms, eye-consciousness arises. The meeting of the three is contact. With contact as condition, there is feeling-sensation. What one feels, that one apperceives. What one apperceives, that one thinks about. What one thinks about, that one mentally proliferates. With mental proliferation as the source, perceptions and notions tinged by mental proliferation beset a man with respect to past, future, and the present forms cognizable through the eye [same with other senses]. (Majjhima Nikÿya, i.111f.) This requires some unpacking: As shown in Chapter 2, early Buddhist thought considered all existence to be contingent. The human personality, our sense of selfhood, is – according to early Buddhist thought – a deluded construct of our unawakened minds. One way the Buddha of the early texts spoke of this selfhood was in terms of the five aggregates: the physical body and its senses; feelings; ideas and concepts; desires and volitions; and self-consciousness. These aggregates, subject to constant change and therefore having no fixed, enduring, existence, come together fleetingly to produce our experience. And although we do experience, that does not mean that we exist as fixed and separate selves. The idea of a self that thinks and acts is, for early Buddhism, simply a concept “applied to and imposed upon what is in fact a plurality of events” (Morrison, 1997, p. 130). Just as with an assemblage parts, The word ‘chariot’ is used, So, when the aggregates exist, There is the convention ‘a being.’ (Saçyutta Nikÿya, i. 135) The process that governs the fleeting coming together of phenomena is spoken of in early Buddhist thought as ‘dependent co-arising’. The doctrine of dependent co-arising states that “all things, whether material, biological, mental, or spiritual, come to be in dependence upon conditions, and when those conditions cease what came to be also ceases” (Morrison, 1997, p.47). The most succinct and general expression of this principle in the early texts is: When this exists, that comes to be; with the arising of this, that arises. When this does not exist, that does not come to be; with the cessation of this, that ceases. (Majjhima Nikÿya,  ii. 32) This formula is found in Pÿli, Sanskrit, and Chinese, attesting to its early pedigree. It is a principle that permeates and informs the whole of Buddhist doctrine and practice (Morrison, 2005). The doctrine of dependent co-arising describes the deep relationship of connectedness between phenomena (Gethin, 1998). To see this, said the Buddha in an early text, is to see the ultimate, and ultimately inexpressible, nature of reality (Saçyutta Nikÿya, ii. 26). To fully penetrate into it is to become Awakened. (Saçyutta Nikÿya, ii. 92) Nothing exists in complete independence from anything else. All phenomena arise in dependence on other phenomena. The early Buddhist texts are replete with formulae that describe different perspectives upon this process, although no one formula can finally describe or pin it down because, of its nature, it is ineffable (Sangharakshita, 1993). The Discourse on the Honeyball, set out above, is one such perspective. It outlines several stages in the process of dependent arising. Firstly, Dependent on the eye and visual forms, eye-consciousness arises. Early Buddhist thought recognised six senses. As well as the five senses that we are familiar with in the West, it accounted the mind itself as a sense. Memories, feelings, thoughts – all of these are regarded as sense impressions (Gethin, 1998). In chapter 2 it was shown that early Buddhist thought regarded the individual, together with his or her experience, as a temporary coming together of five “aggregates”. An alternative analysis in the same body of thought conceived the individual and his or her experience as comprising eighteen elements: “six senses, six classes of sense object, and six classes of consciousness.” (Gethin, 1998, p. 140). There is the eye, the visual object, and visual consciousness; the ear, the auditory object, and sound consciousness; the mind, mind objects (e.g. thoughts, or memories) and mind consciousness; and so on. The interaction of these eighteen elements is the first stage in the emergence of one’s experience. Then, The meeting of the three is contact. Contact, here, refers to the transformation that takes place in sense consciousness when all three aspects of the sensory process come together. One might, for example, have one’s eyes wide open but be so caught up with one’s thoughts that one doesn’t actually see something right under one’s nose (Sangharakshita, 1998). In that case, ‘contact’ would not have occurred. When contact does occur, the transformation in sense consciousness it brings about always has a feeling-tone that may be pleasant, painful, or neutral. Thus, the text says, With contact as condition, there is feeling-sensation. Then, What one feels, that one apperceives. Apperception is the active mental process of assimilating a perception, especially one newly perceived, to a body of ideas already accumulated from previous experience, thereby identifying it (Sangharakshita, 1998). The feeling-sensations involved in each moment of experience condition how one assimilates sense impressions and so cognises one’s experience. This process is on the whole unconscious. What one apperceives, that one thinks about. Having assimilated the new experience into one’s body of accumulated ideas, it emerges into consciousness and one begins to think about it. What one thinks about, that one mentally proliferates. This is where the ‘trouble’ begins. Having begun to think about one or another aspect of one’s experience, mental proliferation usually sets in. With mental proliferation as the source, perceptions and notions tinged by mental proliferation beset a man with respect to past, future, and the present forms cognizable through the eye [same with other senses]. At this point the grammatical structure of the discourse changes. Up to now, the Pÿli third-person structure implied an agent engaged in a series of processes. The changed verb form from here presents the subject as a passive experiencer (Ñÿnananda, 1997). … it is no longer a mere contingent process, nor is the activity deliberately directed, but an inexorable subjection to an objective order of things. At this final stage of sense perception, [one] who has hitherto been the subject now becomes the hapless object. … Like the legendary resurrected tiger which devoured the magician who restored it to life out of its skeletal bones, the concepts and linguistic conventions overwhelm the [unawakened individual] who evolved them. (p. 7) The tangled maze of mental elaboration, with its apparent objectivity, entices and finally overwhelms one. To use more contemporary psychological language, one might describe what has happened here as the arising of a “schema”. The Oxford Dictionary of Psychology (Colman, 2003) defines the term as a mental representation of some aspect of experience, based on prior experience and memory, structured in such a way as to facilitate (and sometimes distort) perception, cognition, the drawing of inferences, or the interpretation of new information in terms of existing knowledge (p. 653) which seems to fit the case well. To sum up the process, as understood in the Honeyball Discourse, the six sense organs, interacting with sense objects, bring about changes in sense consciousness that are pleasant, painful or neutral. Those feelings condition the process of apperception that determines how one cognises the new experience and therefore how one begins to think about it. Once one starts thinking about it, mental proliferation sets in and one takes one’s thoughts to represent reality. Pleasant experiences cause one to think one way about the world, unpleasant ones cause one to think another way. In each case one considers ones thoughts to be fact. To see this in action, one can take an example from the MBCT programme, where Segal et al. (2002) describe a “moods and thoughts exercise”. Participants are given a piece of paper with two scenarios written on it, one on each side of the sheet. Version 1 says: You are feeling down because you’ve just had a quarrel with a colleague at work. Shortly afterward you see another colleague in the General Office and he or she rushes off quickly, saying he or she couldn’t stop. What would you think? (Segal et al., 2002, p.255) Version 2 says: You are feeling happy because you and a work colleague have just been praised for good work. Shortly afterward you see another colleague in the General Office and he or she rushes off quickly, saying he or she couldn’t stop. What would you think? (Segal et al., 2002, p.255) Participants are asked to write down their responses to these scenarios, first using version 1. They are then instructed to turn the paper over and write down their responses to version 2. In the discussion that follows they compare the thoughts and feelings brought up by each description. Often, the first situation is associated with thoughts of being rejected or hurt while the second one may give rise to thoughts of curiosity or concern for the colleague’s welfare (Segal et al., 2002). From the perspective of The Discourse on the Honeyball, a participant’s experience of this exercise can be analysed thus: He or she reads version 1 of the exercise. Senses, sense-objects and sense-consciousnesses interact: the words on the page call forth images and memories (mind-sense objects). These are unpleasant – the sorts of feeling-sensations that come from having had a quarrel. Apperception follows. The unpleasant feeling-sensations condition the way the story fits into the previous pattern of experience. Then comes more conscious thinking. The participants begins to tell themselves the story of what happened. Mental elaboration sets in. The story takes on a life of its own and begins to feed back on the participant. He or she may begin to feel bad about what “happened”. These ‘mind-sense’ experiences in turn feed further apperceptions, that give rise to further thoughts and further mental proliferation. A sense of being hurt or rejected builds up, along with an account of why that happened. In the case of version 2, the pleasant feelings associated with being praised lead to different apperceptions, different thoughts, and a different story about what happened. But in both cases the actual event “you see another colleague in the General Office and he or she rushes off quickly, saying he or she couldn’t stop” is identical. The different stories that the participants tell themselves in either case is conditioned, The Discourse on the Honeyball suggests, by the differences in the feeling-sensations predominant at the time of apperception. In this way, early Buddhist thought asserts, the unawakened time and again entangle themselves in deluded stories about how things are that have no basis in reality (Ñÿnananda, 1997). Whatever one makes of the psychology of perception outlined above (and there is much useful work waiting to be done that considers these processes in greater detail from a contemporary consciousness-studies perspective) an understanding of it vitally informs the way in which one understands the early Buddhist approach to mindfulness practice. For early Buddhist thought, delusional mental elaborations are ineluctably the product of the unawakened condition (Ñÿnananda, 1997). It is, however, possible to become Awakened and since, as shown in Chapter 2, the path to Awakening develops by degrees, it is also possible to become progressively less deluded – less subject to the processes of mental elaboration. One of the ways the early Buddhist tradition suggested this could be done is by addressing the issues of apperception and conceptualisation. Once the stage of [mental elaboration] is reached, the course is set. The proliferations are projected back onto the sense data and the mind continues proliferating by interpreting experience in line with the original biased [apperception]. The stages of [apperception] and initial conceptual reaction are therefore decisive aspects of this conditioned sequence. (Anÿlayo, 2003, p.222) According to early Buddhist thought, a penetrative understanding of the nature of apperception is a prominent cause for Awakening (Anÿlayo, 2003). Crucially, it maintained that apperceptions “are amenable to a process of training” (Anÿlayo, 2003, p.227). As the Buddha put it in the Poýýhapÿda Sutta One’s [apperceptions] arise and cease owing to a cause and conditions. Some [apperceptions] arise through training, and some pass away through training. (Dƒgha Nikÿya, i. 181) And in the Dvedhÿvitakka Sutta: whatever one frequently thinks and ponders upon, that will become the inclination of his mind. (Majjhima Nikÿya, i, 115) Buddhism, because it thus asserts “that perception is changeable by psychological practices such as meditation, assumes a ‘constructivist’ view” (Claxton, 1991, p.25). Underlying this view is the notion that apperceptions are the consequence of mental habits. They are, in more traditional terms, the outcomes of karma. Karma is a Sanskrit term that has found its way into English, where it is often used as a synonym for “fate”. In the Buddhist context, however, karma is much more a description of psychological causality, describing “how habits form and continue over time” (Varela et al., 1992, p. 111). Karma, says Sangharakshita (1991), invariably means “act of volition”. … involuntary actions, whether those of body, speech or mind, do not constitute karma and therefore cannot bring about the results accruing to karma. … unwilled actions do not modify character. (Sangharakshita, 1991, pp. 68 – 69) The Buddhist attitude to cognitive training, recognizing that apperceptions are the outcome of karma, sets out to establish new and – from its perspective, more desirable – habits by directing conscious awareness again and again to the true nature of conditioned existence: that it is, for example, impermanent, insubstantial, and unable to produce lasting satisfaction (Sangharakshita, 1991). For instance, on the basis of an intellectual apprehension of impermanence, one might regularly contemplate the arising and passing away of phenomena. This will give rise in time to apperceptions that apprehend phenomena from the viewpoint of impermanence. With continued practice, awareness of impermanence will become increasingly spontaneous and have an increasing influence on one’s daily experiences, outside of actual contemplation. In this way, sustained contemplation can lead to a gradual change in the operational mechanics of cognition, and in one’s outlook on the world. According to the discourses, such cognitive training can lead to a stage at which one is able at will to cognise phenomena as agreeable or disagreeable. The culmination of training one’s cognitions in this way is reached when one completely transcends such evaluations and becomes firmly established in perceptual equanimity. (Anÿlayo, 2003, p.228) The achievement of that degree perceptual equanimity is beyond the ambit of MBAs. Nonetheless, mindfulness can play a key part in counteracting the automatic and unconscious reactions that are typical of the reactive habits that perpetuate stress. Automatic reactions, triggered out of unawareness, usually compound and exacerbate stress, making what might have remained basically simple problems into worse ones. They prevent us from seeing clearly, from solving problems creatively, from expressing our emotions effectively when we need to communicate with other people, and ultimately they prevent us from attaining peace of mind. (Kabat-Zinn, 1991, p.248) By directing mindfulness to the early stages of the perceptual process – to apperception in particular – one can reshape these habitual patterns, “de-automatizing or deconditioning habits and sub-conscious evaluations” (Anÿlayo, 2003, p.229). From the perspective of this study a crucial aspect of mindfulness training is that it has the capacity to reframe the way in which sense impressions (including thoughts, memories and feelings) are apperceived. Apperceptions, the discourses say, can be made to arise or pass away through a process of training, and when one attends to one’s experience “on purpose, in the present moment, and nonjudgementally” (Kabat-Zinn, 1994, p.4), one is actively engaged in a process of cognitive training. One is seeking to change one’s habits of cognition and all the various elements of mindfulness are intended to subserve this end. The process of automatic cognitive reactivity is described by the Buddha in his discourse on “The Dart” (Saçyutta-Nikÿya, iv, 208), where he describes one of the key differences in their responses to distress between those experienced in the skills of mindfulness and those not experienced. The “uninstructed worldling” he said, experiencing pain, would feel two feelings – a bodily one and a mental one. It was as if he or she was struck by two darts in quick succession, the second dart exacerbating the painful feelings caused by the first. The second dart comprises the painful mental reactions of craving and aversion that follow from the initial experience of pain. By contrast, when the instructed noble disciple is contacted by a painful feeling, he does not sorrow, grieve, or lament; he does not weep beating his breast and become distraught. He feels one feeling – a bodily one, not a mental one. (Saçyutta-Nikÿya, iv, 208) This is because, knowing that clinging gives rise to suffering, he or she has engaged in a process of cognitive training that leads to a direct insight into “the origin and the passing away, the gratification, the danger, and the escape in the case of these feelings” (Saçyutta-Nikÿya, iv, 208). And thus If he feels a pleasant feeling, he feels it detached. If he feels a painful feeling, he feels it detached. If he feels a neither-painful-nor-pleasant feeling, he feels it detached. (Saçyutta-Nikÿya, iv, 208) In other words, those instructed in the path of mindfulness may feel pain, but – having engaged in a process of cognitive training – they feel it without clinging and the consequences of clinging and therefore they are only struck by the first, not the second, dart. This approach resonates strongly with Segal et al.’s (2003) assertion that the core skill in respect of MBCT is “be mindful (aware), let go.” (p.91) Letting go, they say, means relinquishing involvement in the self-perpetuating mental routines that serve distress. … it is the continued attempts to escape or avoid unhappiness, or to achieve happiness that keep negative cycles turning. The aim of the program is freedom, not happiness, relaxation, and so on, … (Segal et al., 2003, p.91 – their italics) Bÿhiya was an ascetic who once approached the Buddha for teachings. The short instruction the Buddha gave him, concerned with cognitive training, led to his immediate attainment of full Awakening. When in the seen will be only what is seen, in the heard only what is heard, in the sensed only what is sensed, in the known only what is known… This is the end of [suffering]. (Anÿlayo, 2003, p.230) The Buddha directs Bÿhiya to maintain a “bare awareness” of whatever is seen, heard, sensed or cognised. By simply registering whatever arises within the senses the sequence of perceptual processes, with all its habitual biases, is interrupted (Anÿlayo, 2003). Not carried away by the usual conditioned sequence of the perceptual process that would otherwise modify his experience through subjective biases and distorted cognitions Bÿhiya becomes one of the Awakened. Free from mental elaborations, he is one of those “who are no longer influenced by subjective biases and who cognise phenomena without self-reference” (Anÿlayo, 2003, p.232). Bÿhiya’s act of bare awareness led first of all to the interruption of the normal pattern of reactive mental processing. This then gave him the opportunity to respond differently to what he experienced. In Bÿhiya’s case the consequences were dramatic. His capacity to maintain bare awareness led to his sudden Awakening. For most people, however, as shown in Chapter 2, early Buddhist thought considered the path to Awakening to be gradual, and characterised by a systematic process of cognitive training. This is a central issue in the teaching and understanding of MBAs, for a certain reading of the Bÿhiya story might give one the impression that attention in the present moment is sufficient, in itself, to allay suffering. It is, but only if one has the capacity to do it to the extent that Bÿhiya himself did. It is not that Bÿhiya was simply more than usually aware of what he perceived. Rather, he was so extraordinarily present that all self-reference ceased in him altogether. Such epiphanies are rare, and for most people the kind of significant change that Bÿhiya sought comes about only after a process of cognitive training that begins to modify the ways they apperceive. As the next text I will consider shows, present moment awareness was more usually thought of in early Buddhism as a vital underpinning for cognitive training and not as an end in itself. ‘The Discourse on Attending with Mindfulness’ (Satipaýýhÿna Sutta) is a key text outlining the early Buddhist system of training. Anÿlayo (2003) signifies its central importance by drawing attention to the large number of canonical discourses that advocate its approach. In translation, the discourse runs to 11 pages of dense instruction in twelve mindfulness meditations, each focussing upon a different object and each seeking a particular psycho-spiritual outcome. The text begins by defining its approach in summary – Here, monks, in regard to the body a monk abides contemplating the body, diligent, clearly knowing, and mindful, free from desires and discontent in regard to the world. In regard to feelings, he abides contemplating feelings … (refrain) In regard to the mind, he abides contemplating the mind … (refrain) In regard to dhammas he abides contemplating dhammas … (refrain) (Majjhima Nikÿya, i. 56, Anÿlayo, 2003, p.31) Although commentators and translators have usually translated the term satipaýýhÿna used in its title and elsewhere in the text as ‘foundation of mindfulness’, Anÿlayo (2003) makes a convincing etymological case for the terms ‘attending with mindfulness’ or ‘presence of mindfulness’, and as the definition section of the discourse quoted above suggests, there are four areas to which the Buddha classically recommended his followers to attend to with mindfulness: the body, feelings, the mind and dhammas. The Pÿli term dhamma assumes a variety of meanings depending on the context in which it is used. Here, as the full text of the discourse later demonstrates, the term applies to some of the classificatory categories taught by the Buddha. In particular, these are the five hindrances, the five aggregates, the six sense spheres, the seven awakening factors, and the four noble truths (Anÿlayo, 2003). These refer to advanced meditation practices during which one examines “whatever is experienced in terms of these dhammas” (Anÿlayo, 2003, p.183). The practice of training oneself in experiencing whatever occurs in meditation in terms of the dhammas is clearly a form of cognitive training. As shown earlier, it is a way of re-training the habits of one’s mind so that one comes, in time, to see things differently – not just to think differently about them. The system of training advocated by the discourse begins, however, with mindfulness of the body, presenting a number of different meditative practices designed to train the practitioner in a heightened awareness of his or her body at all times along with a “balanced and detached attitude towards [it]” (Anÿlayo, 2003, p.122). Beginning with mindfulness of the breath, it then goes on to awareness of bodily posture; clear knowledge of bodily activities; analysis of the body in respect of its anatomical parts; analysis of the body into its elementary qualities; and contemplation of a corpse in nine stages of decay. Here, early Buddhist thought and practice and MBAs both meet and depart. The first three of the Satipaýýhÿna Sutta practices – mindfulness of the breath, awareness of bodily posture and clear knowledge of bodily activities – are incorporated, as shown in chapter 3 of this study, into the MBA system of practice. The last two, analysis of the body into its elementary qualities and contemplation of a corpse in nine stages of decay, are not. In between these two sets lies the practice of analysis of the body in respect of its anatomical parts, which has a certain overlap with the body scan practice used in MBAs but is also, as I will show below, significantly different in its approach. The Satipaýýhÿna Sutta approach to the mindfulness of breathing meditation begins by setting up the conditions for meditation – quiet seclusion and an appropriate, upright, bodily posture. Then the meditator is instructed to breathe in and out mindfully, aware of the length of each breath. The point here is not consciously to control the length of the breath. It simply “reflects the fact that the breath naturally becomes shorter and finer with continued contemplation, owing to increasing mental and physical calmness” (Anÿlayo, 2003, p.130). Next, the Satipaýýhÿna Sutta instructs the meditator to breathe in and out “experiencing the whole body” (Majjhima Nikÿya, i. 56). This approach to mindfulness of breathing meditation, starting with the breath alone and then moving on to mindfulness of the breath and body, is straightforwardly carried over into the MBA system. The second and third of the Satipaýýhÿna Sutta practices, awareness of bodily posture and clear knowledge of bodily activities, are discussed in the MBA context and advocated in a general way. But apart from an introduction to the idea of such continuous mindfulness (by way of the raisin exercise, and the use of mindful movement sequences and mindful walking meditations, as detailed in chapter 3) their formal application in the MBA context is, understandably, less rigorous than in the monastic context of full-time meditative practice that Satipaýýhÿna Sutta presumes. Here, the attempt is clearly to maintain an unbroken continuity of mindfulness of bodily posture throughout the day: When walking, he understands “I am walking”; when standing, he understands “I am standing”; when sitting, he understands “I am sitting”; when lying down, he understands “I am lying down”… (Majjhima Nikÿya, i. 57) Similarly with bodily activities, where the meditator is instructed to “act in full awareness” (Majjhima Nikÿya, i. 57) when looking ahead, looking away, flexing and extending his limbs, wearing his robes and carrying his outer robe and bowl; when eating, drinking, consuming food and tasting; defecating and urinating; standing, sitting, falling asleep, waking up, talking and keeping silent. The next bodily contemplation is the analysis of the body into its anatomical parts. The meditator is instructed to review the body “up from the soles of the feet and down from the top of the hair” (Majjhima Nikÿya, i. 57). That practice would accord to some extent with the body scan practice used in MBAs and detailed in chapter 3. But in the Satipaýýhÿna Sutta attention is particularly drawn to the fact that the body is “full of many kinds of impurity” (Majjhima Nikÿya, i. 57) such as head hairs, body hairs, nails, teeth, skin, flesh, tendons, bones, bone marrow, kidneys, heart, liver, pleura, spleen, lungs, large intestines, small intestines, gorge, faeces, bile, phlegm, pus, blood, sweat, fat, tears, skin-oil, saliva, mucus, fluid in the joints and urine. The aim of the body scan in the context of MBAs is to increase bodily awareness and to develop the skill of deliberately moving attention from one part of the body to the next, the capacity to deliberately shift one’s attention being a particularly valuable cognitive skill in the MBA context (Segal et al., 2002; Kabat-Zinn, 1990; Crane, 2004). In the Satipaýýhÿna Sutta context, however, contemplation of the body in respect of its anatomical parts, while it may also train the meditator in the capacity to shift attention, is primarily aimed at reducing attachment to the body (Anÿlayo, 2003). This approach is extended into the next contemplation, where the meditator is instructed to contemplate the body as comprising four elements: earth, water, fire and air (Majjhima Nikÿya, i. 57). In this way the body is no longer experienced as “I” or “mine”, but simply – according to the ancient Indian scheme of thought – as a combination of four qualities: solidity, liquidity, temperature and motion (Anÿlayo, 2003). This attempt to cultivate detachment is taken a stage further in the final body contemplation in the Satipaýýhÿna Sutta where the meditator is instructed to visualize, in detail, nine stages in the decomposition of a corpse and to conclude that This body too is of the same nature, it will be like that, it is not exempt from that fate. (Majjhima Nikÿya, i. 59) Having concluded the section on contemplation of the body, the sutta moves on to a section dealing with the contemplation of feelings. As noted earlier in this chapter, the Pÿli term for “feeling” is vedanÿ, and it has a specific technical meaning in the context of this sutta. Vedanÿ “does not include ‘emotion’ in its range of meaning” (Anÿlayo, 2003, p.156). Emotions arise in dependence on the initial input provided by feeling but they are more complex mental phenomena than bare feeling itself (Anÿlayo, 2003). The Satipaýýhÿna instructions for the contemplation of feeling are: When feeling a pleasant feeling [he] understands: “I feel a pleasant feeling”; when feeling a painful feeling he understands: “I feel a painful feeling”; when feeling a neither-painful-nor-pleasant feeling he understands: “I feel a neither-painful-nor-pleasant feeling.” (Majjhima Nikÿya, i. 59) And it continues in this way, going on to distinguish pleasant, painful or neutral “worldly” feelings and pleasant, painful or neutral “unworldly” feelings. The distinction between worldly and unworldly here revolves around an evaluation of feeling that is based not on its affective nature, but on the ethical context of its arising. The basic point introduced here is awareness of whether a particular feeling is related to progress or regress on the path. (Anÿlayo, 2003, p. 158) The introduction, here, of an ethical dimension would seem at first sight to stand in contradiction to the assertion often found in MBAs that mindfulness is, of its nature, non-judgemental. Kabat-Zinn (1994), as I have shown previously, classically defines mindfulness from the MBA perspective as “a particular way of paying attention: on purpose, in the present moment, and nonjudgementally” (p. 4). At the same time MBAs do make judgements. MBSR recognises the existence of “catastrophising” thoughts and feelings (Kabat-Zinn, 1992); MBCT similarly makes judgements about the undesirability of “ruminative” mental processes (Segal et al., 2002). Segal et al. (2002) discuss the issue of “relapse signatures”, such as increasing irritability and unsociable feelings – changes in mood “that might signal that depression is developing” (p. 280), and they go on to suggest possible skilful courses of action that participants might undertake to avoid full relapse. The first step, they suggest, is always to take a three minute breathing space. From there, one goes on to take further skilful action based on what one learned on the MBCT course. In this way one can see that MBCT recognises courses of behaviour that are unskilful (ruminative thinking, for example) and those that are skilful, such as taking a three minute breathing space. Relating this back to the Satipaýýhÿna distinctions, skilful behaviour will give rise to one quality of feeling, unskilful to another, and the mindful practitioner will learn to judge accordingly. That said, the approach to cognitive training that early Buddhist thought favours points towards an open, accepting, attitude towards feelings. The Vedanÿsaçyutta (Saçyutta Nikÿya, IV 218), for example, draws parallels between the nature of feelings and the wind, coming from different directions. Winds may be warm, cold, wet or dusty. In the same way, different kinds of feelings arise in the body – pleasant, neutral or unpleasant. And just as it would be foolish to contend with the alternations of the weather, so one ought not contend with the alternations of feelings. Contemplations such as these train the mind in inner detachment. Such detachment, however, was not experienced as a cold, anaesthetic alienation. Rather, by mindfully cultivating skilful pleasures, such as absorption in meditation, without attachment to them, the Buddha and his followers were renowned for the joyous quality of their lives. In the Dhammacetiya Sutta (Majjhima Nikÿya ii 121), for example, King Pasenadi of Kosala tells the Buddha how evident such qualities are amongst them. After contemplation of feelings comes contemplation of the mind. This begins with the meditator being instructed to assess whether his or her current mental state is lustful or without lust, hateful or without hate, deluded or without delusion, contracted, distracted, exalted, un-exalted, surpassed or unsurpassed, concentrated or un-concentrated, liberated or un-liberated. (Majjhima Nikÿya i 59) As Anÿlayo (2002) points out, it is important to note that these contemplations do not involve active measures to oppose unwholesome states, such as lust or hatred, with wholesome ones. Rather the task of mindfulness, from the Satipaýýhÿna perspective, “is to remain receptively aware by clearly recognizing the state of mind that underlies a particular train of thought or thoughts or reactions”(p. 175). This represents a further stage of development, as it were, on the attitude taken within MBAs, where the ‘mindfulness of thoughts’ meditation instruction would be simply to become aware of thoughts just as thoughts – noticing how they arise, linger, and pass away again (Segal et al., 2002) – without examining their individual qualities, as the Satipaýýhÿna approach does. From this point on, the Satipaýýhÿna approach to meditation departs further and further from the approach taken in MBAs. The meditator is instructed to contemplate, in turn, the five hindrances, the five aggregates, the six sense-spheres, the seven awakening factors and the four noble truths. Each of these contemplations is a form of cognitive training, designed to aid the meditator in his or her task of training the faculty of apperception so that, in time, self and the world come to be apperceived as they really are, not as they appear to be – under the sway of delusion. Conclusion The early Buddhist approach to mindfulness, as evidenced in the Satipaýýhÿna discourse, focussed to a large degree on the issue of cognitive training, and this extends beyond a simple attention to present moment experience. The early Buddhist approach to mindfulness, as evidenced in the discourses quoted, is concerned to a large degree with the training of apperception. The ability to train one’s apperceptions in this way, according to early Buddhism, is related to the fact that apperceptions “are the outcome of mental habits” (Anÿlayo, 2002, p. 228), and by way of cognitive training one can establish new and different habits, thereby gradually altering one’s apperceptions and thus one’s view of oneself, others and the world about one. Summary of Chapter Four Noting the fact that MBAs and early Buddhism shared a concern with the processes of mental elaboration, this chapter began by examining the issue of mindfulness and mental elaboration, as it is treated in the early Buddhist texts. It showed how early Buddhist thought regarded mental elaborations as conditionally arisen, and it described the processes which early Buddhism thought of as underpinning the propensity to mental elaboration. Having discussed the relationship between affect, apperception and mental elaboration, both in early Buddhism and in MBAs, the chapter went on to discuss the issue of cognitive training, as it is understood in early Buddhist thought, and it drew out the parallels between the early Buddhist approach and that taken in MBAs. After discussing briefly the issue of ‘bare awareness’, the chapter went on to consider the early Buddhist discourse on the ‘Four Foundations of Mindfulness’ – the Satipaýýhÿna Discourse – focussing on its attitude to mindfulness as a form of cognitive training. The chapter concluded by reiterating the fact that the early Buddhist approach to mindfulness as a form of cognitive training focussed, in large part, on the issue of the training of the processes of apperception which, in time, bring about a dramatic change in the way in which one perceives oneself and the world. Chapter Five: Conclusion Aims of Chapter Five This chapter sets out to provide a summary of the study and to bring the main argument to a conclusion. It considers the implications of this study for theory and practise and makes recommendations for theoretical development and suggests lines of further research. Summary of the Study In Chapter One, two research questions were posed: What part does cognitive training play in the early Buddhist conception of mindfulness practice? and How might the Buddhist approach to cognitive training further enrich our understanding of the Mindfulness-Based Approaches? I hope now to have shown that cognitive training plays a considerable part in the Buddhist conception of mindfulness. In particular, as shown in chapter four, a key element in the early Buddhist approach to Awakening is the training of the process of apperception so that one comes to experience the world in a way that more nearly conforms to the early Buddhist conception of how things really are, as opposed to how they appear to be – under the sway of delusion. The Madhupiݟika Sutta – the Honeyball Discourse investigated in chapter four – described how mental elaborations come about. According to this discourse, the mind and the senses, interacting with physical and mental sense objects, bring about various changes in mental and sensory consciousness, each of which are accompanied by feeling-tones: pleasant, painful or neutral. Those feelings, in turn, condition the process of apperception that determines how one cognises the new experience and therefore how one begins to think about it. Conditioned by the thinking process, mental proliferation sets in and one takes one’s thoughts to represent reality. Pleasant experiences bring about one way of thinking about the world, unpleasant ones bring about another way. In each case one considers one’s thoughts to be fact. In contemporary terms, the feeling-tones that accompany each new element of experience condition the different schemas that arise. So far as early Buddhist thought is concerned, however, this process is not immutable. As the Dƒgha Nikÿya (i. 181) puts it, apperceptions can be made to arise and pass away through training. Thus, although one might feel a particular event to be unpleasant, one can learn, through a process of cognitive training, to apperceive it differently. By directing mindfulness to the early stages of the perceptual process – and to apperception in particular – one can reshape habitual patterns, thus de-conditioning one’s previous habits and unconscious evaluations. In answer to the first research question: “What part does cognitive training play in the early Buddhist conception of mindfulness practice?” I hope to have shown that cognitive training is a highly significant element in the early Buddhist conception of mindfulness and in its approach to the quest for Awakening. That brings us to the second question. “How might the Buddhist approach to cognitive training further enrich our understanding of the Mindfulness-Based Approaches?” The early Buddhist approach to cognitive training involved, as shown in chapter four, a number of meditative and contemplative practices, such as the contemplation of the arising and passing away of phenomena; the qualities of one’s mental states; the constituent elements of the physical body; the nine stages of the decomposition of a corpse; the five hindrances; the four aggregates, and so on. These means of training aim to establish new habits of mind in the meditator so that he or she comes, in time, directly to see things differently. This resonates with what Teasdale (1999) called “metacognitive insight”. As shown in chapter three, Teasdale (1999) distinguished metacognitive insight from metacognitive knowledge. We all know, he says, that thoughts are not facts, and yet, in that form alone such knowledge has little ‘saving’ power in protecting depressively inclined patients from the effects of depressive thought patterns. But the metacognitive insights acquired in Mindfulness-Based Cognitive Therapy programmes can, he asserts, be some of the most important outcomes contributing to the relapse prevention effects of the programme. The same goes for Mindfulness-Based Stress Reduction, where Kabat-Zinn (1991) speaks of how the simple act of recognizing thoughts as thoughts can free one from the distorted realities they often create, allowing for more clear-sightedness and a greater sense of manageability in one’s life. From the perspective of MBAs, such a process of cognitive training would, in time, re-condition the mind to avoid the processes of ruminative thought characteristic of depression (Segal et al., 2002) or the “catastrophising” style of thinking described by Kabat-Zinn (1991). In MBAs, as shown in chapter three, participants learn to relate to thoughts simply as events in the mind, rather than the primary ‘stuff’ of the mind or the self, by two means of cognitive training. Firstly, by learning – in meditation – to see thoughts in the same way as, for example, sounds. Segal et al. (2002) suggest a meditation instruction that asks participants to focus firstly on sounds and then on thoughts and to see that thoughts arise and pass away in the mind in much the same way that sounds do. This perspective is then further enhanced by the meditation instruction, used throughout MBA courses, to note the content of thoughts as they arise and then to let go of them and return to the primary focus of attention – the breath, body, or sounds (Teasdale, 1999). Besides these relatively explicit approaches to cognitive training in the context of MBAs, chapter three noted that there is also an implicit approach. As Segal et al. (2002) point out, the attitude that mindfulness instructors bring to the courses significantly affect what participants learn, and by embodying a calm, open, curious and accepting attitude to whatever arises in the class, instructors show the participants that such approaches to their own difficulties are indeed possible, and this is a vital element in how they come to cognise –and re-cognise – these over the period of the course. Thus cognitive training is a key element in both the early Buddhist and the clinical approaches to mindfulness practice. And yet, when one sees how mindfulness is usually described and defined in the literature on MBAs, the element of cognitive training appears not always to be given a great deal of weight. Kabat-Zinn (1994), for example, as shown in chapter two, classically defined mindfulness as a particular way of paying attention: on purpose, in the present moment, and nonjudgementally. (p.4) Crane (2004), describes it as simply being aware of what is going on, as it is arising, connecting deeply and directly with this and relating to it with acceptance; a powerful act of participatory observation. (p.2) Grossman et al. (2004) see it as a form of naturalistic observation, or participant-observation, in which the objects of observation are the perceptible mental phenomena that normally arise during waking consciousness. (p.36) Bishop et al. (2004), in their operational definition, come closer to drawing out the cognitive training element in mindfulness practise, seeing it as a process of regulating attention in order to bring a quality of nonelaborative awareness to current experience and a quality of relating to one’s experience within an orientation of curiosity, experiential openness, and acceptance. [It is] a process of gaining insight into the nature of one’s mind and the adoption of a de-centered perspective … on thoughts and feelings so that they can be experienced in terms of their subjectivity (versus their necessary validity) and transient nature (versus their permanence). (p.234) Based on some of these definitions, it is possible for mindfulness instructors to approach their teaching with an attitude of seeking simply to bring about a state of purposive, present moment, non-judgemental experience. Useful though that might be in the overall treatment of a patient, it might not – in and of itself – give rise to the kind of cognitive change that Baer (2003) suggests is one of the five key elements in bringing about symptom reduction and behavioural change. As shown above, one of the key elements in the early Buddhist approach to such training is the notion that apperceptions are amenable to training. In the early Buddhist approach, as shown in chapter four, this is brought about through contemplations on ideas such as, for example, the universality of impermanence: phenomena are in a constant state of arising and passing away. Contemplating in this way, meditators come in time to see the world in this way, not just to think about it thus. By directing mindfulness to the early stages of the perceptual process – and to apperception in particular – one can reshape habitual patterns, thus de-conditioning one’s previous habits and unconscious evaluations. One can, for example, learn to see that thoughts are not facts, and that they are not ‘you’ or ‘reality’. These simple observations, or metacognitive insights, can free one from the distorted reality such thoughts often create, allowing for more clear-sightedness and a greater sense of manageability in one’s life (Kabat-Zinn, 1991; Segal et al., 2002). As shown in chapter four, the processes of apperception are often unconscious, but early Buddhist thought asserts that they need not remain so. Gendlin (1997), draws attention to the ways in which functional relationships between experiencing and cognition are mediated by a “felt sense” that may be akin to what early Buddhist thought describes as apperception. As this study draws to a conclusion it ends with two hypotheses that call for further investigation. The first has just been mentioned: that Gendlin’s “felt sense” and the early Buddhist idea of apperception are the same phenomenon. This could be studied along with a deeper investigation into the relationship between contemporary ideas arsing from consciousness-studies and the Buddhist notion of dependent co-arising mentioned in chapter four. Varela et al. (1992); Claxton (1991); Epstein (1995); and others have made a start in this area but there is more work to be done. The second hypothesis is that, in the context of MBAs, mindfulness instruction might be significantly enhanced by instructors drawing participants’ attention more consciously to what in early Buddhist thought is characterised as the early stages of the perceptual process – and to apperception (or, perhaps, the “felt sense”) in particular. Once apperceptions become conscious they become amenable to change. By directing mindfulness to the process of apperception, insights – such as the metacognitive insight that thoughts are not facts (Teasdale, 1999) – can arise. As shown in chapter three, the mindful didactic style used in MBAs encourages participants to adopt an open, inquisitive attitude to whatever arises in their experience and to focus their attention upon it, approaching, rather than avoiding, difficult experiences. The hypothesis is that this process enables apperceptions to emerge more fully into consciousness and this plays a significant part in the process of cognitive change that takes place. Were this hypothesis to be borne out, instructors in the MBAs might gain a fuller understanding of how the approaches have their effects and this might enhance their teaching methods. Summary of this Chapter and Conclusions This chapter has reiterated the main finding of this study: that cognitive training is a significant element in the early Buddhist conception of mindfulness and that the clinical applications of mindfulness practise may be enriched by an investigation of the early Buddhist understanding of the mechanisms through which such training takes place. In particular, by sharing in the early Buddhist understanding that mindfulness can direct attention to the early parts of the perceptual process – to events akin, perhaps, to what Gendlin (1997) termed the “felt sense” – mindfulness instructors can assist participants in coming consciously to experience their own apperceptions more fully and thus arrive at their own metacognitive insights (Teasdale 1999). The above hypothesis is worthy of further investigation. Firstly, one would need to investigate the extent of congruence between Gendlin’s “felt sense” and the early Buddhist concept of apperception. This might take place alongside a consciousness-studies investigation of the relationship between the Buddhist idea of dependent co-arising and contemporary consciousness-studies theory and phenomenology. Then, it would be useful to investigate the effects of mindfulness instructors consciously seeking to draw participants’ attention to the process of apperception. In the mindful didactic style, this is done by inviting participants to investigate their own experience in an open, inquisitive manner – directing their awareness to the “felt sense” of experiences as they occur. The clinical application of mindfulness is, and must always be, a secular project. It does not share in Buddhism’s quest for Awakening. But in its aim to alleviate suffering it has significant intersections with the Buddhist endeavour and further investigations into the relationship between these two fields of practice may, in time, come to enrich both. Appendix Glossary of Pÿli and Sanskrit terms (all terms are Pÿli unless followed by Skt. – meaning Sanskrit) annicasaññaapperception of impermanenceavijjÿignorancebhavachakraWheel of BecomingbhikkhuBuddhist monasticBodhiAwakeningDhamma, Dharma (Skt.)Teaching of the Buddhadhammamental objectdhÿtuphysical or mental element of perceptiondukkha, duåka (Skt.)suffering, distress “lack”kamma, karma (Skt.)ethical actionkamma vipÿkaconsequence of ethical actionsnirÿmisaunworldlypapañcamental elaborationpaýiccasamuppÿdadependent co-arisingphassacontactsaÝkharavolitional effortsati, smŒti (Skt.)mindfulnesssÿmisaworldlytaÝhÿthirstTathÿgataOne Who has Thus Come; epithet for the BuddhaTheravÿda“Doctrine of the Elders”; one of the oldest Buddhist schoolsVajrayÿna (Skt.)“Adamantine Way”; a school of Buddhismvedenÿfeeling-tonevicÿrainvestigation and deliberationviññÿÝaconsciousnessvitakkathe onset or initial application of thoughtvitakketithink about; consider Bibliography Anÿlayo, 2003, Satipaýýhÿna: the Direct Path to Realization, Birmingham: Windhorse Publications. 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Wolcott, H., 1991, Writing Up Qualitative Research, London: Sage.  An early Indian language, allied to Sanskrit and, like Sanskrit, no longer in current use.  The oldest surviving Buddhist school, currently predominant in South and South-East Asia.  A highly ritualised approach to Buddhism currently most commonly found in Tibet  The only other surviving equivalent canon has been so far preserved only in Chinese. It is not yet available in English.  Here, as elsewhere, I have followed Morrison (1997) in rendering taÝhÿ as ‘thirst’, rather than as ‘craving’, as Bhikkhu Bodhi, otherwise the translator of this text, has done.  A system of physical exercises and breathing control used in yoga,  the concentration of an antibody, as measured by the extent to which it can be diluted before ceasing to give a positive reaction with antigen (New Shorter Oxford English Dictionary).  A Chinese martial art and system of callisthenics consisting of sequences of slow controlled movement.  Similar to t’ai chi but focussed more on health benefits than martial art  By “worldling” here, I take Ñÿnananda to mean one who is not Awake.  The text I have used here is the translation found in Morrison (2005). 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