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Address correspondence to Jon Kabat-Zinn, c/o Center for Mindfulness in Medicine, Health Care, and Society, University of Massachusetts Medical School, Shaw Building, 55 Lake AvenueNorth, Worcester, MA 01655.
144
COMMENTARIES
Mindfulness-Based Interventions in Context:Past, Present, and Future
Jon Kabat-Zinn, University of MassachusettsMedicalSchoolFor Francisco Varela, 1945–2001
Baer’s review (2003; this issue) suggests that mindfulness-based interventions are clinically efficacious, but that bet-ter designed studies are now needed to substantiate thefield and place it on a firm foundation for future growth.Her review, coupled with other lines of evidence, sug-gests that interest in incorporating mindfulness into clin-ical interventions in medicine and psychology is growing.It is thus important that professionals coming to this fieldunderstand some of the unique factors associated withthe delivery of mindfulness-based interventions and thepotential conceptual and practical pitfalls of not recog-nizing the features of this broadly unfamiliar landscape.This commentary highlights and contextualizes (1) whatexactly mindfulness is, (2) where it came from, (3) how itcame to be introduced into medicine and health care, (4)issues of cross-cultural sensitivity and understanding inthe study of meditative practices stemming from other cultures and in applications of them in novel settings,(5)why it is important for people who are teaching mind-fulness to practice themselves, (6) results from 3 recent
DOI: 10.1093/clipsy/bpg016
2003 AMERICAN PSYCHOLOGICAL ASSOCIATION D12
studies from the Center for Mindfulness in Medicine,Health Care, and Society not reviewed by Baer but whichraise a number of key questions about clinical appli-cability, study design, and mechanism of action, and (7)current opportunities for professional training and devel-opment in mindfulness and its clinical applications.
Key words:
mindfulness, meditation, mind/bodymedicine, mindfulness-based stress reduction (MBSR),mindfulness-based cognitive therapy (MBCT).
 [Clin Psy-chol Sci Prac 10: 144–156, 2003] 
I
appreciate the opportunity to comment on Baer’s (2003;this issue) review of mindfulness training as clinical inter-vention and to add my own re
fl
ections on the emergenceof mindfulness in a clinical context, especially in a journalexplicitly devoted to both science and practice. The uni-verse of mindfulness
1
brings with it a whole new meaningand thrust to the word
 practice,
one which I believe has thepotential to contribute profoundly to the further develop-ment of the
fi
eld of clinical psychology and its allied disci-plines, behavioral medicine, psychosomatic medicine, andhealth psychology, through both a broadening of researchapproaches to mind/body interactions and the develop-ment of new classes of clinical interventions.
THE GROWING INTEREST IN MINDFULNESS
I
fi
nd the Baer review to be evenhanded, cogent, and per-ceptive in its description and evaluation of the work thathas been published through the middle of 2001, work thatfeatures mindfulness training as the primary element invarious clinical interventions. It complements nicely therecent review by Bishop (2002), which to my mind ignoressome of the most important, if di
ffi
cult to de
fi
ne, featuresof such interventions in its emphasis on the perceived need
 
to reduce to a clinical algorithm the complexity of thepractice and nuanced delivery of mindfulness-based stressreduction (MBSR).Both Baer and Bishop pose important questions that re-quire addressing if researchers and clinicians are ultimatelyto understand mindfulness and its clinical utility. Both re-views agree that the scienti
fi
c study of mindfulness andMBSR to date su
ff  
ers from a range of methodologicalproblems, a view with which I concur. When a
fi
eld is inits infancy, it is not uncommon for the
fi
rst generation of studies to be more descriptive of the phenomenon rather than definitive demonstrations of e
ffi
cacy. Attempts at thelatter tend to evolve over time after the potential value of a new approach has been at least tentatively established.This now appears to be the case with mindfulness-basedinterventions. Both Baer and Bishop conclude that enoughevidence has now accumulated to warrant the develop-ment ofmore methodologically rigorous investigations of both the clinical e
ffi
cacy of mindfulness training in variousspeci
fi
c disorders and the possible mechanisms and path-ways through which it might exert characteristic e
ff  
ectswithin those speci
fi
c disorders.The very fact that an increasing number of studies onmindfulness and its clinical applications are being fundedand published and that an increasing number of doctoraltheses on mindfulness are appearing in Dissertation Ab-stracts suggests that this is an area that is currently sparkingconsiderable interest, perhaps driven primarily by the in-tuition that new dimensions of therapeutic bene
fi
t andnovel insights into mind/body interactions might accruethrough its exploration. Because interest in mindfulnessand its applications to speci
fi
c a
ff  
ective conditions is likelyto increase even further, particularly within the cognitivetherapy community with the development of mindful-ness-based cognitive therapy (MBCT;Segal, Williams, &Teasdale, 2002) and with the use of mindfulness withindilectical behavior therapy (DBT;Linehan, 1993), it be-comes critically important that those persons coming tothe
fi
eld with professional interest and enthusiasm recog-nize the unique qualities and characteristics of mindful-nessas a meditative practice, with all that implies, so thatmindfulness is not simply seized upon as the next prom-ising cognitive behavioral technique or exercise, decon-textualized, and “plugged”into a behaviorist paradigmwith the aim of driving desirable change, or of 
fi
xing whatis broken.
WHAT EXACTLY IS MINDFULNESS, AND WHERE DOESIT COMEFROM?
As pointed out by Baer, mindfulness has to do with par-ticular qualities of attention and awareness that can be cul-tivated and developed through meditation. An operationalworking de
fi
nition of mindfulness is:the awareness thatemerges through paying attention on purpose, in the pres-ent moment, and nonjudgmentally to the unfolding of experience moment by moment. Historically, mindfulnesshas been called “the heart”of Buddhist meditation (Thera,1962). It resides at the core of the teachings of the Buddha(Gunaratana, 1992;Hanh, 1999;Nanamoli & Bodhi, 1995),traditionally described by the Sanskrit word
dharma,
whichcarries the meaning of 
lawfulness
as in “the laws of physics”or simply “the way things are,”as in the Chinese notion of 
Tao.
One might think of the historical Buddha as, amongother things, a born scientist and physician who had noth-ing in the way of instrumentation other than his ownmindand body and experience, yet managed to use thesenativeresources to great e
ff  
ect to delve into the nature of su
ff  
eringand the human condition. What emerged fromthis arduous and single-minded contemplative investiga-tion was aseries of profound insights, a comprehensiveview ofhuman nature, and a formal “medicine”for treat-ing itsfundamental “dis-ease,”typically characterized as thethree “poisons”:greed, hatred (aversion), and ignorance/delusion (unawareness).Of course, the Buddha himself was not a Buddhist. Onemight think of dharma as a sort of universal generativegrammar (Chomsky, 1965), an innate set of empiricallytestable rules that govern and describe the generation of the inward,
fi
rst-person experiences of su
ff  
ering and hap-piness in human beings. In that sense, dharma is at its coretruly universal, not exclusively Buddhist. It is neither a be-lief, an ideology, nor a philosophy. Rather, it is a coherentphenomenological description of the nature of mind,emotion, and su
ff  
ering and its potential release, based onhighly re
fi
ned practices aimed at systematically trainingand cultivating various aspects of mind and heart via thefaculty of mindful attention (the words for mind and heartare the same in Asian languages;thus “mindfulness”in-cludes an a
ff  
ectionate, compassionate quality within theattending, a sense of openhearted, friendly presence andinterest). And mindfulness, it should also be noted, beingabout attention, is also of necessity universal. There isnothing particularly Buddhist about it. We are all mindful
COMMENTARIES ON BAER145
 
to one degree or another, moment by moment. It is an in-herent human capacity. The contribution of the Buddhisttraditions has been in part to emphasize simple and e
ff  
ec-tive ways to cultivate and re
fi
ne this capacity and bring itto all aspects of life. In this regard, mindfulness certainly re-ceived its most explicit and systematic articulation anddevelopment within the Buddhist tradition over the past2,500 years, although its essence lies at the heart of other ancient and contemporary traditions and teachings as well,approaches that can be of great value in re
fi
ning one’s ownpractice, insight, and teaching (see, for example, ChuangTsu, 1964;Krishnamurti, 1999;Lao-tsu, 1988;Maharaj,1973;Maharshi, 1959;Thakar, 1972;Tolle, 1999).Mindfulness is the fundamental attentional stanceunderlying all streams of Buddhist meditative practice:theTheravada tradition of the countries of Southeast Asia(Thailand, Burma, Cambodia, and Vietnam);the Maha- yana (Zen) schools of Vietnam, China, Japan, and Korea;and the Vajrayana tradition of Tibetan Buddhism found inTibet itself, Mongolia, Nepal, Bhutan, Ladakh, and nowlarge parts of India in the Tibetan community in exile. Itshould be noted that these traditions all have variousschools, subtraditions, and particular texts that they reveremore than others, so the actual practices and emphases re-garding mindfulness can vary considerably, even withinone tradition, such as Theravada or Zen (Goldstein, 2002).Nevertheless, mindfulness, as elucidated by the Buddha intwo discourses, the Anapanasati Sutra (Rosenberg, 1999)and the Satipathana Sutra (Thera, 1962), is the core teach-ing and constitutes the foundation upon which all of thesevarious forms and traditions rest. In these traditions theactual practice of mindfulness is, however, always nestedwithin a larger conceptual and practice-based ethicalframework oriented towards nonharming (an orientationit shares with the Hippocratic tradition of Western medi-cine). This “view”includes a skillful understanding of howunexamined behaviors and what Buddhists would call anuntrained mind can signi
fi
cantly contribute directly to hu-man su
ff  
ering, one’s own and that of others. It also includesthe potential transmutation of that su
ff  
ering through med-itative practices that calm and clarify the mind, open theheart, and re
fi
ne attention and action.Over the past 40 years or so all of these Buddhist tradi-tions have taken root in the West to one degree or another (Bachelor, 1994;Fields, 1992), and have by this time beentaken up by several generations of Westerners, who prac-tice these methods in their own lives on a daily basis as wellas through participation in periodic teacher-led, intensivemeditation retreats, which can last from a weekend to 3months or more (see, for example, Goldstein, 1987;Gold-stein, 2002;Goldstein & Korn
fi
eld, 1987;Walsh, 1977,1978). This phenomenon represents a cultural shift thatmay be only in its infancy. Nevertheless, it provides a rangeof rich resources for personal practice and dialogue that cancontribute toward the training and development of a co-hort of highly competent teachers, from a wide variety of professional backgrounds, committed to the e
ff  
ective de-livery of authentic mindfulness-based interventions in var-ious settings.Mindfulness is often spoken of synonymously as “in-sight”meditation, which means a deep, penetrative non-conceptual seeing into the nature of mind and world. Thisseeing requires a spirit of perpetual and persistent in-quiry—as in, “What is this?”—toward whatever arises inawareness, and toward “who is attending,”“who is see-ing,”“who is meditating.”Its role in deep inquiry and thecultivation of insight have led some to argue that thatmindfulness provides a unique perspective that can informcritical issues in cognitive science, neurophenomenology,and attempts to understand the cognitive underpinningsofthe nature of human experience itself (Varela, Thomp-son,& Roach, 1991).
CROSS-CULTURAL AND PARADIGM ISSUES INWORKING WITH THE CONSCIOUSNESS DISCIPLINES
From the perspective of the behavioral sciences, mindful-ness can be thought of as a “consciousness discipline,”as de-scribed by Walsh in a seminal paper (Walsh, 1980) thatexplicates the generic paradigm of the meditative traditionsand their associated disciplines and shows how such disci-plines might be approached empirically by the behavioralsciences without falling into paradigm clash or a range of category errors, which can unwittingly ignore or dismissthe deepest and most subtle features of such practices,thereby predisposing investigators to draw erroneous con-clusions. Thus, in encountering the consciousness disci-plines and the question of their possible adaptation andapplication in secular clinical or medical contexts, it iscritically important to treat mindfulness and the traditionsthat have articulated it much as a respectful anthropolo-gistwould treat an encounter with an indigenous culture(Davis, 1998) or a di
ff  
erent epistemology (Zajonc, 2000).This intimate sensitivity will be necessary to understand,evaluate, and preserve essential elements of the universal
CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE
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V10 N2, SUMMER 2003146
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John Snell

The heart of Buddhism

reply03 / 06 / 2011
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