There was an article in the Guardian this week which reports that mindfulness based CBT [MBCBT] performs as well as (in fact, slightly better than) medication in the treatment of depression. This would seem to be very good news, except for the fact that neither treatment appears particularly effective. Nearly half of the patients in this study who underwent either form of treatment suffered relapses, which raises important questions about why both treatments failed to help the unfortunate half of patients who were unsuccessfully treated. Nevertheless, these results are hardly negligible, especially when we consider that unlike drugs, MBCBT has no side effects and is probably the cheaper form of treatment, as well. And taking up mindfulness for whatever purpose, even the treatment of depression, presents the possibility that it may lead someone to embrace spirituality and find a more meaningful life. Moreover, Buddhism has always dealt with the matter of suffering as its principle concern, so in some way it seems quite natural that mindfulness should be used for treating depression, even in clinical contexts. Still, reservations are in order, not least because clinical science must forbid itself from seeing what Buddhism expressly claims to know. So what does Buddhism know that about mindfulness that might tells us something about the pitfalls of the practice?
Buddhism affirms that one of the factors that makes mindfulness effective is its linkage to wisdom and morality, the two other key principles in its trio of essential spiritual values. But wisdom for Buddhism has specific connotations which distinguish it from other types of wisdom, especially the sort of worldly wisdom which all too readily serves in mundane affairs. In Buddhism, wisdom arises from selfless intentions and the desire to understand the Buddha's teaching, but it may actually be detrimental to worldly success. Similarly, Buddhist morality is not so much a matter of obeying rules passed down from on high as it is about ridding the mind of its defilements and freeing it of any tendencies that produce craving. But this may all seem a matter of religious practice, far removed from the practical concerns of the everyday world. Moreover, at least in regard to the use of mindfulness for psychotherapy, Buddhism's emphasis on morality and wisdom may actually impede its therapeutic utility. As every therapist knows, many clients' primary understanding of morality comes from their experience of it as the rod with which they have always been beaten. And as for cultivating wisdom, most clients hardly have a clue as to where to begin. So in treating something like depression then, it is only right that mindfulness should be assessed in terms of its therapeutic utility and not its adherence to Buddhist doctrine.
Still, there is another aspect to the practical wisdom that Buddhism possesses about mindfulness which seems to feature less importantly in its application as a therapeutic practice. This has to do with addressing what makes mindfulness so difficult, frustrating and unrewarding, even to those who are dedicated to it. Buddhism identifies five hindrances to meditation: sense desire, ill will, torpor and sloth, restlessness and worry, and sceptical doubt. Knowing about these hindrances and learning how to negotiate them is a sound way of strengthening meditation, as well as overcoming the obstacles themselves. Even so, many dedicated practitioners can still find themselves stuck in the doldrums in which nothing seems to happen. This is a mental state that strongly resembles depression and is characterised by lethargy, chronic doubt and sometimes, pervasive anxiety. It can also provoke depression outside of meditation, which is why some people feel compelled to abandon the practice. It should not be assumed that depression occurs only to weak practitioners, either. The great Zen master and founder of Soto Zen, Dogen experienced depression, as did the Rinzai Zen master Hakuin (whose graceful, haunting ink painting "Two Blind Men Crossing a Log Bridge" serves as the logo for this website) when he suffered "Zen sickness", an enervating condition that was brought on by his intense efforts to reach enlightenment. In fact, encountering depression in a rigorous spiritual practice is not uncommon at all, as such expressions as "the Dark Night of the Soul" and "a Spiritual Desert" suggest. But what Buddhism and other spiritual traditions have all developed are ways of dealing with these problems when they arise. So what resources does therapeutic mindfulness draw on when mindfulness no longer seems effective and may even be making matters worse?
I ask this question out of genuine curiosity, for I am sure that strategies for intervening when therapeutic mindfulness goes wrong must have been developed. Moreover, my acquaintance with MBCBT therapists who are also Buddhists reassures me about their intentions as therapists. More teachers than technicians, these therapists mostly want to help their clients manage their lives without the anxiety and stress that drive people to therapy. And when they succeed, MBCBT therapists are certainly entitled to take satisfaction in work well done. Still, as with all therapy, questions must remain whenever it doesn't work, especially as MBCBT seems to place such emphasis on its therapeutic protocols. We might ask, for instance, if MBCBT's results could be improved if it refined its protocols, making its applications more targeted and exact. Perhaps. But I suspect that the secret ingredient in all therapy is the trust that develops between client and therapist in the course of the therapeutic encounter. This does not mean that other factors are unimportant or negligible for the success of therapy. The techniques that MBCBT imparts to its clients really do matter for is success. But those techniques, which can be learned by reading a book or watching a video on-line, are usually imparted so much better by a therapist who cares about the quality of the transmission.
I have one further question about mindfulness and therapy, but only time can tell the answer. Therapy has always had new methods which were supposed to revolutionise things until they faded into routine procedures. Hypnosis first fascinated Freud as a healing technique until he abandoned it for free association. And free association itself was once thought to be the only way therapy could work effectively until some therapists elected to use other methods. In fact, both hypnosis and free association can still work, as can focussing, the body awareness technique that accesses the so-called second brain of the enteric nervous system which governs our emotional reactions. So will therapeutic mindfulness follow the pattern of these other techniques which were at first wildly praised before becoming just another way of dealing with psychological problems? I suspect so. But perhaps this is the wrong question to raise about mindfulness. Perhaps the better question is how is mindfulness helping therapy now?
One of the more common, as well as most enduring prejudices against psychotherapy is that it is alleged to make people so self preoccupied that they become excessively consumed with what they are thinking and feeling and by doing so, lose all vital connection to others, to the world, to life itself. In truth, becoming so self preoccupied that finding meaningful relationships based in reciprocity and mutual trust becomes impossible would indeed constitute a problem for anyone who happened to suffer from it. But the idea that such a problem must always trace back to an introspective disposition and that its solution can be found only by making an outward engagement in the world often comes a little too automatically, usually without consideration of the actual difficulties that the person in question may be experiencing. Moreover, whenever introversion is condemned as a disposition, little thought seems to be given to the dangers of extroversion, the opposite disposition, in which preoccupation with external affairs turns the inner world into a dim and alien realm of experience. In contrast to the introvert, the problems that the extrovert tends to face are less about his failure to form relationships with others than they are about finding any meaning within his internal experience of being himself. Yet, although this can be no less serious a problem than what the introvert faces in his inability to relate to others, the dangers of introversion are usually regarded as somehow more serious.
Ideally, of course, there should be a balance between the two tendencies and we might say as generalised prescriptions that the introvert should find renewal by looking outward and the extrovert should be encouraged to cultivate a more reflective attitude in order to discover the enriching possibilities of introspection. But as a therapist, I find that popular opinion greatly favours extroversion over introversion and tends to regard introversion as almost inherently pathological. And this bias, I would argue, suggests a widespread popular mistrust about the uncertain realities of the inner world that affects almost every individual's attempts to make sense of his or her self experience. Don't look within, such conventional wisdom advises, for there is nothing there but dangerous and empty self indulgence. And most of us believe this advice, even if it is unhelpful or even harmful, as well as untrue. Although an introspective turn can often indicate a withdrawal into sterile inwardness, looking within can also hold the possibility of finding depth and meaning within the farthest reaches of inner experience. As mystics of virtually all traditions attest, travel far enough within the self and an inner light that illuminates all things can be found. The question then is how such a potentially enlightening journey can be made, especially when the far more common experience of turning inward is to find confinement in a dark space within which the only possible light could seem to come from exterior sources.
The terms introversion and extroversion were coined by Jung to describe a person's characteristic orientation to either the inner or outer realm of experience. According to Jung , these characteristics are not much different than physical traits like height and eye colour and so forth, but unlike such physical characteristics which remain more or less fixed throughout a person's life, a psychological disposition can change over the course of a lifetime to become its opposite in accordance with the principle of enantiodromia, a pre-Socratic concept which Jung took from Heraclitus. In Jungian terms, enantiodromia may be understood as a psychological process of transformation in which a conscious position reaches an extreme limit and then begins to change into its opposite. How this principle applies in any particular case will always be an open question, but in general, both introverts and extroverts would experience life from different orientations before migrating to the opposite position. What induces this profound shift is that if an orientation becomes deeply unsatisfying it will produce any number of symptoms of distress verging on breakdown. Indeed, Jung went so far as to claim that a neurosis is a signal of a psychic imbalance that desperately requires redress.
People may come into therapy suffering from all manner of psychological complaints, but they seldom think about their difficulties in explicit terms of introversion or extroversion. Although there is nothing inherently wrong with being either introverted or extroverted, either disposition could be problematic if it impedes adaptation or personal growth. If, for example, a client comes in claiming that he is suffering from loneliness and an inability to relate to people, his problems probably spring from an introverted disposition. And if another client comes in complaining about how bored and empty she feels whenever she finds herself alone, it is likely that her extroverted temperament rules her life. As always, it would be necessary to examine each case to see how a person's disposition affects the problem at hand. The starting point in all cases would be what the client finds disturbing in his or her self experience. In general, introverts will tend to focus on themselves and their feelings of self inadequacy, while extroverts are more likely to complain about external circumstances and why they can't achieve insight for the conditions they chronically suffer. But introversion and extroversion require each other as complements or counterparts for locating self experience in the world. This means that we are never without others even when we are alone. But it also means that we are always alone in our self experience, even in the company of others. RD Laing once made an astute observation by analysing the term self consciousness which illustrates this duality in action. On the one hand, self consciousness refers to being self aware as an individual subject; on the other, it refers to being self aware as an object of interest to others. But the two perspectives oscillate so frequently that we may fail to notice that they are actually apart.
Indeed, it is possible to be trapped in a cycle of futility as either an introvert or extrovert, though in rather different ways. An introvert may rehearse his frustrations in endless rumination, while an extrovert may follow a pattern of heedless behaviour without any meaningful self reflection. One may be immured in self defeating preoccupation with possibilities that will never occur, while the other may be infatuated with trivial things. But in both cases, the self becomes engrossed in affairs that will bring neither satisfaction nor self insight. Buddhism teaches that by regarding both self and world as transitory phenomena they can be seen for what they are and the light of consciousness can shine with impartial radiance over all things. Both the inner and outer become illuminated, but the light comes from within. Indeed, that is what consciousness in itself is and by cultivating mindfulness, or awareness of things without preference or self interest, consciousness becomes increasingly clear. Although finding the light of awareness does require introspection, it as much a matter of seeing through our self preoccupations as it is of looking inward and away from from external concerns.
Finding the light within is not what psychotherapy is usually all about. Therapy usually goes into those dark cul-de-sacs of the self that hold the shame or trauma of past experiences with scant hope of finding any light within them. Yet, making things conscious is what therapy is all about, even if reaching such consciousness appears to be a humble achievement. Sometimes, therapy does as much as it can do by helping people stop being foolish. But that in itself may open the possibility of becoming more self aware and even of finding the light within.