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?