MINDFULNESS MEDITATION:

AN INTEGRATION OF PERSPECTIVES FROM

BUDDHISM, SCIENCE AND CLINICAL PSYCHOLOGY

A Dissertation Submitted to the Faculty of the

California Institute of Integral Studies

by
Miles I. Neale

In Partial Fulfillment
Of the Requirements for the Degree of
Doctor of Psychology

San Francisco, California

2006

CERTIFICATE OF APPROVAL

I certify that I have read Mindfulness Meditation: An Integration of

Perspectives from Buddhism, Science and Clinical Psychology by Miles I.
Neale, and that in my opinion this work meets the criteria for approving a
dissertation submitted in partial fulfillment of the requirements for the
Doctor of Clinical Psychology degree in Clinical Psychology at the
California Institute of Integral Studies.

______________________________________
Denise Scatena, Ph.D.
Professor of Psychology
Committee Chair

______________________________________
David Lukoff, Ph.D.
External Reviewer

 2006 Miles I. Neale

Miles Ian Neale

Denise Scatena, Ph.D., Committee Chair
California Institute of Integral Studies, 2006
MINDFULNESS MEDITATION: AN INTEGRATION OF PERSPECTIVES
FROM BUDDHISM, SCIENCE AND CLINICAL PSYCHOLOGY
ABSTRACT
Mindfulness meditation is a two-and-a-half millennia-old Buddhist
spiritual practice that focuses on the development of introspective
consciousness. The present research provides a comprehensive, multiperspective overview and synthesis of the applications and effects of
mindfulness meditation. The need for the current study is significant
given that recently in the West mindfulness meditation has increasingly
been a subject for empirical investigation, as well as a clinical intervention
for a wide variety of medical illnesses and psychiatric disorders. The
objective of the current study was thus to integrate the traditional
Buddhist aspects of mindfulness with findings from contemporary
empirical research.
In conducting this integration, the theory, application, and effects
of mindfulness meditation as described in early Buddhist psychology was
reviewed. A comprehensive literature review of the past 50 years of
health-related studies was then undertaken to determine the
physiological, neurological, and psychological effects of mindfulness

iv

meditation, as well as its efficacy as a treatment protocol in a clinical

context.
The specific areas of focus for the literature review included
meditation, concentration, mindfulness meditation, mindfulness-based
stress reduction (MBSR), mindfulness-based cognitive therapy (MBCT),
dialectical behavior therapy (DBT), attentional control, insight meditation,
Buddhist meditation, vipassana, and mind/body medicine. Publications
of theoretical nature, single case studies, clinical trials, meta-analyses,
existing reviews of the literature and scholarly books in the areas of focus
were included.
In this review significant neuro-biological and clinical evidence to
suggest that mindfulness meditation is an effective treatment for a wide
range of medical and mental health issues was found and discussed,
including points of convergence and mutual relevance between these
current Western applications and traditional Buddhist perspectives.
It was concluded that there is a need for a greater number of fullscale clinical trials regarding the effects of mindfulness meditation in the
clinical context, with an emphasis on more rigorous methodological
standards. In addition, it was concluded that Buddhist theory and
applications of mindfulness meditation have yet to be sufficiently
analyzed and synthesized into Western applications in health-related
contexts.

DEDICATION
This work is dedicated to my mentor,
Dr. Joseph J. Loizzo
An ideal introject who rouses my optimal potential.
Whose belief in me internalized as a seed of self-confidence.
Who guided me into the lineage of the jewel tree refuge.
All credit belongs to you, all blame I drive into one!
May the adversity I endured during graduate training,
Purify my past negativity.
And may the merit accrued,
Be dedicated to the liberation of all sentient beings.
Welcome blade-wheel you have again come full circle!

vi

AKNOWLEDGMENTS

This project was influenced and inspired by several people, whom I

would like to acknowledge. I would first like to thank my committee
chairperson, Dr. Densie Scatena for her patience and guidance through
this challenging dissertation process, and for respecting and fostering my
unconventional learning style and interests. Thanks also to my external
review member, Dr. David Lukoff, for his thoughtful critique and
suggestions that assisted in improving my work, and for his professional
contributions to the emergence of spiritual diagnoses and treatments in
mainstream psychology.
I would like to express my deep appreciation to several Buddhist
teachers who blessed me with their wisdom and compassion, including
my guru, the late Achariya Godwin Samararatne, with whom I took
refuge under the Bodhi tree in Bodh Gaya at age 21. Godwins simplicity
and delight in teaching loving-kindness and mindfulness provided a
propitious entryway into the unbroken legacy of the Buddha and have
remained a continuous inspiration throughout this project and my life.
My gratitude extends also to my teachers at Tibet House, New York,
including Dr. Robert Thurman for his sharp intellect, animated charisma
and refined craft in conveying the magnificent jewel of Tibetan Buddhism
and Dr. Mark Epstein for his elegant and lucid presentations of the
interface between Buddhist meditation and psychotherapy.

vii

Finally, I am grateful to my parents, Ian and Michele Neale, and my

brother Julian for their unconditional acceptance and financial support, as
well as to my dear friends Nasli Batliwala, Michael Sheehy, Kemal Arsan,
Brooke Radder, Dan Hirshberg and Emily Wolf, for their companionship
along this sojourn. None of this would be possible or even worthwhile
without them. In our interactions I have glimpsed the dawning of
interconnectivity. Continue all to fearlessly fallow the blue light into the
life between.

viii

TABLE OF CONTENTS

Abstractiv
Dedicationvii
Acknowledgments...viii
Chapter 1: Introduction..1
Defining Mindfulness Meditation2
Significance of the Study...6
Purpose of the Study.7
Chapter 2: Approach and Method..9
Integrative Literature Review Method.9
Data Gathering Procedures...12
Key Words and Search Terms...13
Buddhist Texts14
Organization of the Study.........15
Chapter 3: Mindfulness Meditation in Early Buddhist Psychology19
Origins of the Buddha and His Teachings....19
History of the Buddha20
Teachings of the Buddha23
The Three Vehicles...23
The Four-Noble Truths Framework....24
First Noble Truth..25
Second Noble Truth..26

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Third Noble Truth.27

Forth Noble Truth...28
Freedom From Suffering29
Selflessness...29
Overcoming the defilements..31
The Three Higher Trainings .33
Ethical conduct (Sila)...33
Attentional control (Samadhi)....33
Wisdom (Prajna)..34
Buddhist Meditation Techniques and Topographies...34
Concentration Meditation .36
The Three Realms of Experience ...37
The first realm...38
The second realm..38
The third realm.39
The Path of Concentration..39
Mindfulness Meditation .41
Buddhist Instructions and Texts on Mindfulness42
The Path of Insight ..46
Insight Stages 1 and 2..47
Insight Stage 3..48
Insight Stage 4..49
Insight Stage 5..49

Insight Stages 6 and 7..50

Insight Stage 8..51
Summary.53
Chapter 4: Mindfulness Meditation in Mind/Body Medicine.55
Towards a Science of Enlightenment..55
History of Clinical Meditation Research 59
Physiological Effects of Mindfulness ..64
Cardiovascular System and Disease...66
Blood Pressure and Hypertension ..69
Metabolic and Respiratory System .71
Muscle Tension .71
The Value of Mindfulness Meditation in Medical Populations72
Chronic Pain .72
Anxiety ..75
Psoriasis .80
Cancer ...82
Summary...86
Chapter 5: Mindfulness Meditation in Cognitive Neuroscience.. .88
Introduction...88
Neurological Correlates of Mindfulness Meditation...91
EEG and Alpha Activity91
Alpha Blocking Versus Alpha Habituation..95
EEG and Theta Activity100

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Brain Laterality and Hemispheric Dominance101

PET, fMRI and EEG Studies..105
Neuroplasticity..112
Summary.115
Chapter 6: Mindfulness Meditation in Clinical Psychology.118
Introduction.118
Buddhism and Clinical Psychology..120
Mindfulness Meditation Compared to Psychotherapy123
Theoretical Models Combining Techniques126
The Sequential Model128
The Simultaneous Model...130
Mindfulness Meditation and Ego Development..132
The Ego Ideal and the Ideal Ego...135
Reparenting the Ego.137
Contraindications of Mindfulness Meditation...140
Complications and Negative Effects...140
Regression to Primary Narcissism...141
Emergence of Repressed Material142
Review of Adverse Effects144
Stage Model of Meditative Complications...144
Stage 1. Preliminary practice.145
Stage 2. Access concentration146
Stage 3. Samadhi146

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Stage 4. Insight...147
Clinical Value of Mindfulness Meditation148
Mindfulness Meditation: Adjunct to Psychotherapy...148
Mindfulness and Short-term Therapy...148
Mindfulness and Long-term Therapy..148
Mindfulness and Psychoanalysis..150
Mindfulness-Based Psychotherapies...152
Mindfulness-Based Cognitive Therapy....152
Dialectical Behavior Therapy156
Mechanisms of Clinical Effects in Mindfulness...160
Exposure161
Cognitive Change.162
Self-management...163
Relaxation...164
Acceptance.164
Deautomatization..166
Lifting Repression..167
Existential Relief.168
Meta-Analyses and Methodological Issues .171
Points of Comparison Between Meta-Analyses..171
Inclusion Criteria...171
Target Populations.172
Mean Effect Size.172

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Methodological Weaknesses..173
Potential Benefits.176
Summary.178
Chapter 7: Integration and Synthesis.179
The Central Role of Disidentification...179
Disidentification in Buddhist Meditation180
Disidentification in Mind/Body Medicine..184
Disidentification in Neuroscience186
Disidentification in Psychotherapy.186
Buddhism and Psychology Reconsidered..187
Chapter 8: Conclusion...191
Recommendations for Future Research.192
Methodological Rigor...192
Specific Areas to Be Addressed192
Qualitative Data and Subjective Accounts..194
Further Implications.195
Secular Versus Traditional Meditation.195
Qualifications of the Clinician...196
Reintegration: A Return to the Buddhist Origins198
Concluding Remarks203
References 206
Appendix A: Abbreviations of Buddhist Texts...240
Appendix B: Glossary of Buddhist Terms...241

xiv

CHAPTER 1: INTRODUCTION

In the last several decades, within various disciplines of western

healthcare, there has been a burgeoning interest in complementary and
integrative treatments for mental and physical disorders. While great
strides have been made in surgical and pharmacological protocols, and
while biomedical research continues to reveal more precise and effective
treatments for a wide range of diseases, mechanistic and reductionistic
approaches have increasingly been recognized as limited. A holistic
framework has recently emerged to address the shortcomings of the
allopathic medical model, developed within the dualistic Cartesian
paradigm of the early 17th century. Rather than target symptoms alone,
integrative approaches seek to provide greater health benefits and lasting
relief by focusing on the mind/body connection. These approaches
address negative attitudes, behaviors, and lifestyles, which underlie
disease and psychopathology.
This growing interest in both popular and professional circles
within the United States and Europe, that safe, effective, and inexpensive
alternatives are needed to complement conventional healthcare, results
from two separate factors: First, the cost of modern medicine is increasing
due to the complexity and sophistication of current treatments; and
second, there is an escalating number of so-called diseases of
civilization, where conventional surgical, psychotherapeutic, and
pharmacological treatments are only partially effective (Loizzo, 2000).
These stress-exacerbated diseases include, anxiety, depression, and
addiction, as well as heart disease and cancer. As a result, Western
1

researchers have looked to traditional systems of healing found in other

parts of the world, such as meditation and yoga, for examples of
noninvasive, self-care regimens that have stood the test of millennia of
human use (Davidson & Harrington, 2001; Goleman, 1979, 1981, 2003a,
2003b; Gyatso, 1997; Gyatso, Benson, Thurman, Gardner, & Goleman,
1991; Hayward & Varela, 2001; Houshmand, Livingston, & B.A. Wallace,
1999; Zojonc, 2004).

Defining Mindfulness Meditation

Traditionally, meditation has been a broad term used to categorize
an array of spiritual forms of introspective consciousness-shaping
practices. Recently, the term meditation has gained more frequent use in
medical literature, indicating a shift from its primary designation as a
religious practice to a more widespread definition as a secular means to
help train ones attention (Kabat-Zinn, 1994). In their 1996 work, Mandle,
Jacobs, Arcari and Domar pointed out that there were over 1,000 studies
on meditation that could be found in the literature, with the number
currently having grown to more than 1,500 (Gremer, Ronald, & Fulton,
2005). This increase reflects a growing interest in determining and
verifying the health benefits of meditation. On the other hand, the
misperception, pervasive in early research, that all meditation techniques
were alike, negated the unique psychological effects, therapeutic value,
and even the potential complications associated with different practices
(Dunn, Hartigan, & Mikulas, 1999).

Since the late 1950s Western physicians, psychologists, and health

researchers have been studying the psycho-physiological effects of various
types of meditation, resulting in several literature reviews (Barrows &
Jacobs, 2002; Banadonna, 2003; Jarrell, 1985; Murphy & Donovan, 1999; D.
H. Shapiro & Walsh, 1983; West, 1987). The most widely known and
researched techniques are Transcendental Meditation (TM) (OrmeJohnson & Farrow, 1977) and Bensons (1975) relaxation response method.
The present research focuses exclusively on the Buddhist practice known
as mindfulness meditation (Skt, smirti; Pali, sati) and its more advanced
derivative, insight meditation (vipassana).
Mindfulness comes from the Pali word sati and the Sanskrit word
smirti, which connotes awareness, attention, and remembering. The
background and foreground of consciousness are, respectively, awareness
and attention. Awareness provides global scanning and continuous
monitoring of experience, while attention heightens sensitivity towards a
restricted amount of experience, allowing for a deepening of ones focus
and investigation. The term remembering is also pivotal, given the fact that
mindfulness is the continued intention to remain present, and to
volitionally refrain from mental engagement that disrupts the unity of
awareness and attention (Gremer, Ronald, & Fulton, 2005).
Mindfulness has been variously defined as paying attention in a
particular way: on purpose, in the present moment, and
nonjudgmentally (Kabat-Zinn, 1994, p. 4); as bringing ones complete
attention to the present experience on a moment-to-moment basis
(Marlatt & Kristeller, 1999, p. 68); and, simply as attentional control
3

(Teasdale, Segal, & Williams, 1995, p. 54). A more psychologically

oriented description defines mindfulness as a limber state of mind
(Langer, 1989, p. 70); and as a cognitive process that employs the creation
of new categories, openness to new information, and awareness of more
than one perspective. According to Hirst (2003), being mindful requires
the person to attend, to be consciously aware of, the emergent nature of
phenomena in consciousness, and to recognize the nature of attachments
made to these phenomena as they occur (p. 360).
Mindfulness is more than a cognitive, perceptual function; it is
awareness of present experience with acceptance (Gremer et al., 2005, p.
7). Kabat-Zinn (1990) and Shapiro, Schwartz, and Bonner (1998) list 12
qualities or attitudes that support the practice of mindfulness, including
nonjudging, nonstriving, acceptance, patience, trust, openness, letting go,
gentleness, generosity, understanding, gratitude, and loving kindness.
Vietnamese Buddhist meditation master Nat Hanh (1976) defines
mindfulness as, keeping ones consciousness alive to the present reality
(p. 11); while the German Buddhist monk and scholar Nyanaponika (1972)
describes it as the clear and single minded awareness of what actually
happens to us and in us at the successive moments of perception (p. 5).
The Sri Lankan monk, Gunaratana (1991), provides a more esoteric
explanation, stating that mindfulness cannot be fully captured in words,
because it is subtle, nonverbal, beyond conception, and must ultimately be
experienced.
Mindfulness is both a psychological state of receptive awareness,
and a systematic meditation practice that is used to develop skill in
4

nonjudgmental perceptual receptivity. The reader should note that for the
remainder of the research the term mindfulness refers to the actual
meditation practice. For those interested in the former, Langer (1989)
discussed the cognitive model of mindfulness without emphasis on the
meditative approach. Mindfulness can also be contrasted with
mindlessness, a state of being as if on automatic pilot, involving
preoccupation, forgetfulness, carelessness, inattention, disassociation from
thoughts and feelings, and habitual response (Brown & Ryan, 2003).
Langer (1989) adds that mindlessness is distinguished from mindfulness
by behaviors that are guided by habit, trapped by rigid mind sets, and
oblivious to time, context, or novel perspective.
Although interest in mindfulness has increased within the past 10
years, various researchers (Bishop, 2002; Feldman, Hayes, Kumar &
Greeson, 2004) have argued that the term itself has yet to be sufficiently
operationalized, thereby compromising research and making it difficult to
measure its construct validity. In response, Bishop et al. (2004) recently
proposed the following operationalized definition of mindfulness:
sustained attention of present experience with an attitude of openness,
curiosity, and acceptance. Generally speaking, such variations in
definition depend upon the domain of psychology in which the subject is
discussed, either clinically or nonclinically. Clinical definitions are more
consistent with the traditional concept of mindfulness in Buddhism,
emphasizing present moment awareness with attitudes of acceptance and
nonjudgment towards unpleasant and distressing experience. Nonclinical
definitions emphasize concepts of learning and creativity.
5

Significance of this Study

Although mindfulness meditation has its origin in the 2,500-year
old pan-Asian Buddhist tradition, it is now relevant to the contemporary
medical and psychiatric disciplines of the West. Along with other
meditation practices researched in the last 50 years, mindfulness
meditation has grown from a relatively unfamiliar concept, to a
controversial and misunderstood technique, to a generally accepted
therapeutic intervention with proven efficacy. A large number of
empirical reviews focusing specifically on mindfulness meditation have
recently appeared in the literature (Baer, 2003; Banadonna, 2003; Bishop,
2002; Brown & Ryan, 2003; Gremer et al., 2005; Grossman, Niemann,
Schmidt, & Walach, 2004; Hirst, 2003; Loizzo, 2000); several standardized
treatment protocols incorporating mindfulness are now available (Hayes,
Strosahl, & Wilson, 1999; Kabat-Zinn, 1982; Linehan, 1993b; Loizzo, 2004;
Marlatt & Gordon, 1985; Segal, Williams, & Teasdale, 2002); more than 240
hospital and clinics nationwide and abroad offer mindfulness-based
health programs for patients (Salmon, Santorelli, & Kabat-Zinn, 1998); and
National Institute of Health initiatives to fund such centers reflect a
consensus among professionals about their cost-effectiveness and proven
clinical value (Goleman & Gurin, 1993).
As the visibility and utility of mindfulness meditation increase in
Western culture, clinicians and researchers will be asked by their patients
and colleagues to evaluate current empirical findings, provide clinically
sound treatment recommendations, and knowledgeably discuss the
nature, benefits, and limitations of these techniques. This may pose an
6

unexpected difficulty, given that only a short time ago meditative

techniques were dismissed either as a placebo or as an obsessive religious
ritual from foreign cultures (Loizzo, 2000). The present study offers an
integrative review of classical Buddhist and contemporary empirical
findings. These findings provide an overview of the potential effects and
benefits of mindfulness meditation, while placing it in the therapeutically
rich paradigm from which it originated, that of Buddhism. The growing
empirical support and popular demand for integrative approaches to
health and well-being make a review of the empirical evidence of
mindfulness meditation necessary and timely. Such a study would be
useful to both individuals in the public sector who wish to make informed
choices about their healthcare options, and to practicing professionals who
want to develop complimentary approaches to treatment.

Purpose of the Study

The purpose of this study was to integrate Buddhist, scientific and
clinical perspectives regarding the effects of mindfulness meditation, in
order to provide a more comprehensive presentation of the subject,
including empirical and clinical areas of Western investigation,
contextualized within the seminal Buddhist tradition from which it arose.
First, I examined the utility and effects of mindfulness meditation from
the Buddhist perspective to provide the contextualizing foundation often
neglected in secularized investigations and applications created by
researchers and clinicians for the western population. Second, I reviewed
the neuro-psycho-biologic effects of mindfulness meditation as presented
7

in the last 50 years in scientific research. Third, I examined the manner

and degree of success in which mindfulness meditation has been utilized
therapeutically as a clinical intervention for various medical and mental
health issues.
This study focused on four primary objectives. The first objective
was to reconnect empirical research and clinical applications of
mindfulness with original Buddhist theory and practice. The second
objective was to make accessible the major findings, controversies, and
developments in our understanding of mindfulness meditation, including
its causal mechanisms, over the past 50 years of research. The third
objective was to distinguish the effects of mindfulness meditation from
other meditation techniques such as concentration forms of meditation
and from other psychotherapeutic techniques such as free association.
The fourth objective was to determine the efficacy of mindfulness
meditation as it has been applied to various disorders in medical and
clinical context. The intended audience of this study includes
professionals interested in both expanding their therapeutic repertoire
and interested in the current empirical findings regarding meditation; and
the public, who could benefit from having a greater knowledge about the
nature and effects of alternative and integrative approaches that have
grown in visibility in the mainstream culture.

CHAPTER 2: APPROACH AND METHOD

The Integrative Literature Review Method
The present study utilized the Integrative Literature Review (ILR)
method, in order to summarize the accumulated state of knowledge
concerning the relation(s) of interest and to highlight important issues that
research has left unresolved" (Creswell, 1994, p. 22). An ILR brings readers
up-to-date on the state of the knowledge on the issue and suggests areas
that need more research (Webster & Watson, 2002). According to Tarraco
(2005), the integrative literature review is a form of research that reviews,
critiques, and synthesizes representative literature on a topic in an
integrated way such that new frameworks and perspectives on the topic
are generated (p. 356). This expectation that literature reviews provide
new frameworks or ways of conceptualizing an issue is consistent with
Whettens (1989) observation that the mission of a theory-development
journal is to challenge and extend existing knowledge, not simply to
rewrite it (p. 491).
The ILR is a relatively uncommon method employed in research,
and a particularly novel approach for a dissertation. To date there is not a
well established format to organize an ILR as there is for other empirical
methods (Webster & Watson, 2002). Tarracos (2005) report provides
some initial guidelines for an ILR stateing that the method attempts
to counter the misconception that integrative literature reviews are
less rigorous or easier to write than other types of research articles.
On the contrary, the integrative literature review is a sophisticated
form of research that requires a great deal of research skill and
insight. (p. 356)

An ILR is typically employed when information about a subject has

broadened and matured, and requires consolidation and synthesis to
bring it up-to-date, or when a subject is novel and ambiguous and
requires integration from various sources to provide an initial overview
(Creswell, 1994). In addition, Tarraco (2005) suggest an IRL is appropriate
when contradictory evidence appears, when there is change in a trend or
direction of a phenomenon and how it is reported, and when research
emerges in different fields (p. 359).
Based on the above factors, the following justifications are provided
for the use of the ILR method in this study of mindfulness meditation.
1. Meditation has been a subject of empirical research for more
than 30 years (Murphy & Donavon, 1999) with well over 1,500 published
studies on the topic (Gremer et al., 2005). As a subset of this extensive
investigation, mindfulness meditation has been the focus of increased
attention over the last decade (Baer, 2003); and may be considered a
mature subject in need of consolidation and synthesis.
2. There have been several conflicting reports in the literature
concerning the effects of mindfulness, specifically, if it may be classified as
a distinct state of consciousness (Holmes, Solomon, Cappo, & Greenberg,
1983), what type of brain activity it produces (Davidson et al., 2003); and,
most notably, its causal mechanisms and potential for therapeutic change
(Baer, 2003; Loizzo, 2000).
3. There have been significant developments in our understanding
of mindfulness meditation as cross-cultural collaboration and dialogue

10

between Buddhist contemplatives and scholars and Western scientists and

researchers increases (B.A. Wallace, 2005, 2006).
4. Mindfulness meditation is no longer a subject confined to the
fields of behavioral medicine; rather, it has expanded into the domains of
clinical psychology and more recently into cognitive neuroscience. To
reflect this last point, the present study examined: (a) the utility and
effects of mindfulness meditation from the Buddhist perspective, (b) the
neuro-psycho-biologic effects of mindfulness from a scientific perspective,
and (c) the therapeutic effects and efficacy of mindfulness applied in
various treatment contexts from a clinical perspective. There was thus
sufficient justification to support the use of the ILR method for the present
study of mindfulness meditation.
The goal of the ILR is to provide synthesis of conflicting reports,
developments in understanding and research direction, and findings from
various fields of inquiry. According to Tarraco (2005) who addressed the
nature of this synthesis,
Synthesis integrates existing ideas with new ideas to create a new
formulation of the topic or issue. Synthesizing the literature means
that the review weaves the streams of research together to focus on
core issues rather than merely reporting previous literature.
Synthesis is not a data dump. It is a creative activity that produces a
new model, conceptual framework, or other unique conception
informed by the authors intimate knowledge of the topic. The
result of a comprehensive synthesis of literature is that new
knowledge or perspective is created despite the fact that the review
summarizes previous research. (p. 362)
Webster and Watson (2002) indicated that once a synthesis of the
literature was created, typically it culminated in one of four forms: (a) a

11

new research agenda, (b) a taxonomy of constructs, (c) an alternative

conceptual framework, or (d) a metatheory.
The present study is an attempt to contribute to a new agenda for
future research by posing questions that will stimulate interest in the
origins of Buddhist psychology, an area that has gone largely unnoticed.
Currently the general conceptualization of mindfulness is largely of a
mind/body technique that is of benefit when integrated with other
western behavioral and cognitive psychotherapies (Lau & McMain, 2005;
Roemer, 2002). This study provides an alternative conceptual framework
that establishes mindfulness meditation as a self-sufficient and time-tested
therapeutic technique within a coherent and sophisticated psychological
system.

Data Gathering Procedures

The first step in gathering the literature reviewed was an electronic
search of the PsychINFO and PubMed databases, after which a manual
search was conducted of the reference sections of relevant articles for
related theoretical publications, single case studies, clinical trials, and
reviews of the literature. Reviewing the citations from the most current
articles obtained through the database search allowed for the retrieval of
an older body of literature. Once the literature was compiled, a staged
review was conducted. A stage review consists of an initial review of
abstracts, then an in-depth review of either just the methods and findings
sections; or the entire report, depending on its significance to the
argument (Tarraco, 2005, p. 361).
12

Other literature reviews and meta-analyses on the subject were

examined first, so that I could orient myself to the scope of the literature
and the major publications that were repeatedly cited when crossreferenced. The literature was organized into three main categories that
constituted the subject matter of each distinct chapter: (a) Mind/body
medicine and physiological effects, (b) cognitive neuroscience and brain
effects, and (c) clinical psychology and therapeutic effects. Within each of
these chapters an attempt was made to follow a sequence of themes: (a)
historical context or perspective, (b) theoretical or philosophical basis,
and, (c) practical applications or evidence.
Key Words and Search Terms
Key words and search terms included: meditation, concentration,
mindfulness meditation, Mindfulness-Based Stress Reduction (MBSR),
Mindfulness-Based Cognitive Therapy (MBCT), Dialectical Behavior Therapy
(DBT), Attentional Control Training (ACT), insight meditation, Buddhist
meditation, vipassana, and mind/body medicine. Searches for these terms were
conducted individually and then combined with terms such as therapy,
psychotherapy, and treatment.
To narrow the focus of the review, studies involving Zen meditation,
zazen, Tibetan meditation, tantric meditation, visualization, Transcendental
Meditation (TM), relaxation, relaxation response, guided imagery, yoga, Relapse
Prevention (RP) and progressive muscle relaxation were excluded unless
required to make comparative arguments.
Searches were conducted for studies examining the effects of
mindfulness meditation on adult physiology, neurochemistry, brain
13

function, and biology as well as cognitive, affective, and behavioral

processes. The present study further reviewed the history of meditation
research in the United States, examining data from 1950 to 2006. Books,
presentations, dissertations, and other scholarly materials were all
considered if they matched the inclusion criteria.
Buddhist Texts
A number of primary Buddhist texts (sutta) and secondary
commentaries were used to provide an understanding of the application
and effects of mindfulness meditation as espoused in its originating
context. To narrow the focus of Buddhist literature, mostly primary
textual resources from the classical school of Buddhism (Theravada)
represented in the Pali Canon, were included. Linguistic translations of
primary Buddhist texts were beyond my scope of training and ability;
therefore, the English versions of several significant texts were utilized.
An online database (Access to Insight) of Pali texts translated largely by
Thanissaro Bhikhu was utilized for this literature search. Names of Pali
texts were typically translated and italicized and an abbreviated form was
placed in parenthesis. A list of abbreviations is included in the appendix.
Throughout the study the original Pali and Sanskrit (Skr) terms were
translated, and the original italicized and placed in parenthesis in order to
provide scholars with a reference for terms for their own translation. A
glossary of Buddhist terms is also included in the appendix of the
dissertation.
Additional sources, such as articles, books, and presentations,
pertaining exclusively to mindfulness and insight meditation were
14

included to supplement primary texts. Examining the reference sections of

major works on mindfulness meditation led to a sufficient pool of credible
authors on the subject.
Organization of the Study
Chapter 3 examines the theory and practice of mindfulness
meditation as it is presented in various Buddhist sources. There are only a
limited number of empirical studies (Banadonna, 2003; D. Brown, 1986; D.
Brown & Engler, 1986; Campos, 2002; Goleman, 1976; Hirst, 2003; Miller,
1999; Wilber, Engler, & D. Brown, 1986) that have explored the utilization
and benefits of mindfulness as described in traditional Buddhist
psychology. The tendency is for researchers to extrapolate meditation
techniques from their contextual basis in the so-called prescientific
systems of Asia, and integrate them into their own Euro-American health
disciplines. This extrapolation increases the risk of key components of the
practice being lost in transition and translation (Fields, 1992; Loizzo &
Blackhall, 1998). The process of reductionism and extraction is a symptom
embedded within a more disparaging worldview of Eurocentric
imperialism and materialism (Weber, 2001), which repudiates the mutual
exchange of ideas, denies the possibility of genuine cross-cultural
comparison, and stifles the potentially enriching collaborative research
between two divergent yet equally viable traditions (Loizzo, 1995, 2001,
2006a; Rubin, 1996; Thurman, 1998). The present study, as has been
proposed by Loizzo and Blackhall (1998), attempts to assess what the

15

Buddhist spiritual tradition offers by respecting its integrity and viewing

it as a coherent system.
Chapter 4 begins with history of the Buddha and his teachings.
Then the Buddhist psychological diagnosis of suffering, its etiology, its
prognosis, and its treatment, as formulated in the Four Noble Truths
framework, is reviewed. The three unconscious impulses, attachment,
aversion, and delusion, which produce suffering; and the three higher
trainings (adhisiksya), ethics, meditation, and wisdom, which promote cure,
are examined and explained. Finally, the therapeutic techniques of calm
abiding meditation (samatha) and special insight meditation (vipassana) are
discussed, in addition to their corresponding cartographies, the path of
tranquility and the path of insight. These paths trace the stages of the
development of consciousness as produced through each meditation
technique.
Chapter 5 addresses the history, physiological effects, and medical
efficacy of mindfulness meditation within the discipline of mind/body
medicine. First, a justification for the examination of higher states of
consciousness produced by meditation is provided. This is followed by a
brief historical overview of Western meditation research. Then, there is an
analysis of the medical studies that focus on the physiological effects of
mindfulness meditation, specifically, the relaxation response (Benson,
1975); the process of deautomatization (Deikman, 1966; Rubin, 1991); and
cognitive-affective uncoupling (Kabat-Zinn, 1982). The chapter concludes
by reviewing disease-specific studies, which determine the efficacy of

16

mindfulness meditation-based interventions in the treatment of chronic

pain, anxiety, psoriasis, and cancer.
In Chapter 6, there is a review of meditation research in the field of
cognitive neuroscience. Through analysis of electroencephalographic
(EEG) and brain imaging studies, evidence is provided to support the fact
that mindfulness meditation has a unique set of neurological
characteristics that distinguish it from other states of consciousness, such
as waking, rest, or sleep. Studies also demonstrate how meditation can
assist psychotherapy by creating a lateral shift from left to right brain
dominance, thereby providing access to affective and unconscious
domains of human experience. Research is used to demonstrate that
meditation activates neural plasticity by cultivating an enriched
environment in the nervous system, one that activates growth and repair
of the brain.
Chapter 7 reviews meditation research within the discipline of
clinical psychology. A brief cross-cultural comparison of Buddhism and
clinical psychology will be conducted, particularly as it pertains to the
prevalent notion in the literature that Buddhist mindfulness and
conventional psychotherapy address different levels of ego-development.
A section on the potential complications of meditation will follow, in
order to highlight areas where the application of meditation is
contraindicated. Last, there is a critical evaluation of various clinical
outcome studies and literature reviews that determine the precise
mechanisms and clinical efficacy of mindfulness-based psychotherapies,

17

such Mindfulness-Based Cognitive Therapy (MBCT) and Dialectical

Behavioral Therapy (DBT).
Chapter 8 integrates findings from the preceding chapters into a
coherent presentation of the utility, effects and benefits of mindfulness
meditation. The material is organized around the concept of
disidentification, which was found to be a common thread weaving
insights from Buddhism, medicine, neuroscience and psychology
together. The dissertation ends with a concluding chapter that provides
recommendations for future study in the field of meditation research.

18

CHAPTER 3: MINDFULNESS MEDITATION IN EARLY BUDDHIST

PSYCHOLOGY

Origins of the Buddha and His Teachings

Buddhism is a living wisdom tradition, based upon personal
transformation achieved through rigorous training in self-examination
and self-correction (budhisodhana) (Loizzo, 2006b). After 40 years of
research, eminent Buddhist scholar Robert Thurman (1997) defined
Buddhism as engaged realism. Buddhism was founded by the 5th-century
Indian prince and ascetic, Siddhartha Goutama, who is known as the
Buddha, meaning Awakened or Enlightened One. He was not a prophet
or messianic figure; rather, he was a man who, through a radical internal
revolution and direct observation of self and reality, achieved a state of
consciousness free from suffering (Thurman, 1997). Due to this
transformation, the Buddha systematized a set of replicable teaching
methods in order for others to achieve a similar optimal psychological
state.
As a result, some researchers have argued that Buddhism is more
appropriately conceptualized as a psychology or mind science rather than
a religion, as we in the West have viewed it (Thurman, 1984). Over the last
2,500 years the Buddhas teachings (dharma) have spread throughout Asia,
developing new philosophical tenets and adapting its presentation to the
preexisting values and rituals of the culture it has entered (Fields, 1992).
Thurman (1997) argued that the natural evolution of Buddhism continues
in America and Europe today as the ancient spiritual teachings and
methods interact with Western mind sciences such as medicine,
19

psychology and education. Western literature is extensive regarding the

life of the Buddha and the historical and philosophical developments of
Buddhism in India and Tibet (Bercholz & Kohn, 1993; Conze, 1980, 1996;
Cowell, 1984; De Silva, 2000; Fields, 1992; Harvey, 2000; Keown, 1996;
Powers, 1995; Robinson & Johnson, 1982; Rahula, 1975; Sopa & Hopkins,
1989; Strong, 1995; Thurman, 1984).
History of the Buddha
There is some disagreement as to the Buddhas dates of birth and
deathRahula (1975) states that the historical Buddha lived from 563 B.C.
to 483 B. C., while other scholars (Conze, 1980; Keown, 1996) postulate
that he may have lived as much as a century later. The Buddha was born
to the rulers of the Shakya clan, hence his appellation Shakyamuni, which
means "sage of the Shakya clan. The legends that grew up around him
hold that both his conception and birth were miraculous. As an infant, he
was presented to an astrologer who predicted that he would become
either a great king or a great spiritual teacher, and he was given the name
Siddhartha ("He who achieves His Goal"). His father, evidently thinking
that any contact with unpleasantness might prompt Siddhartha to seek a
life of renunciation as a religious teacher, and not wanting to lose his son
to such a future, protected him from the realities of life by confining him
within the walls of their many seasonal palaces (Robinson & Johnson,
1982).
The unpleasant truths of poverty, disease, and old age were
therefore unknown to Siddhartha, who grew up surrounded by every
material comfort. When he was 29, he went on four consecutive chariot
20

rides outside the palace grounds and for the first time saw an old person,
a sick person, and a corpse. On the fourth trip, he saw a wandering holy
man whose asceticism inspired Siddhartha to follow a similar path in
search of freedom from the suffering caused by bondage to the infinite
and painful cycle of birth, death, and rebirth (samasara). Because he knew
his father would try to stop him, Siddhartha secretly left the palace in the
middle of the night and sent all his belongings and jewelry back with his
servant and horse.
Siddhartha abandoned his family and their luxurious existence,
and for the next 6 years lived the life of an ascetic, studying with several
great masters of meditation, and attempting to conquer worldly desires by
engaging in various austere yogic disciplines. Finally, as he lay close to
death as the result of his regimen of fasting, he accepted a bowl of rice
from a young girl; and once he had eaten, he realized that physical
austerities and ecstatic states of absorptive meditation (samadhi) were not
the means to achieve spiritual liberation. At a small village in northern
India named Gaya, he sat all night beneath a pipal tree and meditated.
After transmuting the primal human instincts of compulsion, aversion,
and self-preoccupation, Siddhartha attained enlightenment and became a
Buddha at the age of 35 (Robinson & Johnson, 1982). It is recorded in the
Jaravagga (Jrv), the 11th chapter of the classic Buddhist collection of verses,
the Dhammapada (Dhp), that upon his awakening the Buddha proclaimed,
I wandered through rounds of countless births,
Seeking but not finding the builder of this house.
Sorrowful indeed is birth again and again.
Oh, house builder! You have now been seen.
You shall build the house no longer.
21

All your rafters have been broken,

Your ridgepole shattered.
My mind has attained to unconditional freedom.
Achieved is the end of craving.
(Thanissaro and Access to Insight, 1997a)
For 7 weeks after his enlightenment, the Buddha sat meditating
under the pipal tree; and following this period of reflection, hesitation,
and doubt, he decided to teach others what he had learned, encouraging
individuals to follow a path that he called the middle way. This path
avoided extremes of self-indulgence and self-denial in order to penetrate
the true nature of reality, which he defined as causal interdependence
(pratityatsamutpada), relativity (shunyata), and liberation (nirvana). He gave
his first sermon, known as the Four Noble Truths, in a deer park in
Sarnath, on the outskirts of the holy city of Benares; and soon had many
students. For the next 45 years, the Buddha traveled throughout
northeastern India, delivering his teachings of freedom from suffering
achieved through his methods of calm abiding (shamata) and special
insight (vipassana).
The Buddha established the worlds first monastic order, which
received full patronage and support by the laity and was quickly accepted
into the religiously tolerant milieu of ancient India (Fields, 1992). This
allowed the monks to be exempted from their conventional social
responsibilities in order to pursue a higher profession as seekers of selfknowledge and freedom (Thurman, 1998). Although the Buddha
presented himself only as a teacher and not as a god or as an object of
worship, it is said that he performed many miracles during his lifetime,
based upon the exceptional capacities of mind that he had developed
during his meditation and enlightenment (Robinson & Johnson, 1982).
22

Traditional accounts relate that he died at the age of 80 in Kushinagara,

after ingesting a tainted piece of food (Keown, 1996).
The Buddhas physical death is a significant component of his
legacy according to the Way of the Elders (Theravada), since it emphasized
the fact that he was mortal and that his body was subject to the laws of
material reality. This concept was confirmed in his final words, which
were recorded in the Maha-parinibbana Sutta (Mpn), and found in the 16th
chapter of the Diga-Nikaya (Dn). Speaking to his assembly of monks, the
Buddha said, It is the nature of all conditioned things to vanish. Strive for
the goal with diligence (Thanissaro and Access to Insight, 1998).
The Buddhas body was cremated and the remains distributed
among his followers who enshrined them in large hemispherical burial
mounds (stupas), a number of which have become important pilgrimage
sites. The Buddhas sermons (sutra), monastic code of ethics (vinaya), and
psychological insights (abhidharma), all of which constituent the early
Buddhist doctrinal canon (tripitaka), were meticulously preserved by an
oral tradition and later committed to writing in both Pali and Sanskrit
languages. There are reports of monks in Burma and other Buddhist
countries today who can still recite by memory the thousands of stanzas
that comprise the doctrinal canon (tripitaka) (Kornfield, 1983).
Teachings of the Buddha
The Three Vehicles
Buddhist teachings can be loosely categorized into three main
divisions, also known as vehicles (yanas), each unique in its expression
and aim (Thurman, 1997). The first division, known as the Lesser Vehicle
23

(Hinayana), or the Way of the Elders (Theravada) occurred within the first
500 years after the Buddhas death. This division represents the classical
monastic approach aimed at personal and individual liberation. It
emphasizes a spirit of renunciation from the world of dissatisfaction and
rebirth (samsara), and is practiced today in Southeast Asia. The second
wave of teachings, known as the Great Vehicle (Mahayana), or Messianic
tradition, began roughly around the 1st-century of the Common Era. At
the present time, it is predominantly practiced in East Asia. These
teachings emphasize altruism, universal responsibility, and a social ethic,
thereby widening the scope and aim from individual liberation to social
transformation.
The third wave of teaching is known as the Adamantine, or
Apocalyptic Vehicle (Vajrayana), which represents the esoteric tradition of
Buddhism that occurred towards the middle of the first millennium A.D.
and was preserved in Tibet and other Himalayan nations. This final
vehicle focuses on individual and social liberation simultaneously, while
emphasizing expedient, highly refined, and often secret arts (tantras) to
accomplish their aims (Powers, 1995). Despite the many philosophical
schools and cultural manifestations of Buddhism, the central doctrine of
the Four Noble Truths and the import of mindfulness (Skt smitrti; Pali sati)
and insight (vipassana) meditation remain common threads (Robinson &
Johnson, 1982).
The Four Noble Truths Framework
Early Buddhist psychology is based upon a central medical model
adapted from ancient Indian Ayurvedic medicine known as the Four
24

Noble Truths (ariya-sacca) (Loizzo & Blackhall, 1998). The fourfold model
is contained in an early Buddhist text called Setting the Wheel of Dharma in
Motion (Dhammacakkappavattana Sutta) (Dcp) (Thanissaro and Access to
Insight, 1993) found in the Samyutta Nikaya (Sn) of the Pali Canon. The
Four Noble Truths reveal the undeniable reality of suffering (dukkha) and
its causes, as well as the potential of its cessation and the means to its
cessation (Nyanaponika, 1965). According to the Buddhist-oriented
psychologist and author Jeffery Rubin (1985, 1991, 1996), the Four Noble
Truths can be viewed as the Buddhas four-part medical model to address
human suffering: (a) The first truth delineates the symptoms, (b) the
second provides diagnoses, (c) the third determines the prognosis, and (d)
the fourth prescribes the treatment plan. The Four Noble Truths are not
pillars of faith, for they do not provide relief through intellectual
understanding or pious belief. Instead, they are propositions to be acted
upon, tested, and verified through ones own experience (Batchelor, 1997).
First Noble Truth. The First Noble Truth defines the basic
characteristic of the unenlightened human life as one of difficulty and
dissatisfaction (dukkha). According to its precepts, every individual
experiences sickness, pain, old age, and death repeatedly through
countless rebirths. The First Noble Truth is not a pessimistic view that
regards life as completely hopeless or nihilistic. Rather it begins by
acknowledging and accepting mankinds predicament, and attempts to
lessen the influence of self-imposed sources of distress, such as harmful
behavioral habits (karma), unrealistic cognitive tendencies (samskara), and
afflictive emotional reactions (klesha). The First Noble Truth teaches
25

individuals to accept those things that cannot be changed while

addressing the issues that intensify their condition, thereby enabling them
to enjoy life on lifes terms. Primarily it is meant to inspire renunciation,
the abandonment of attachment to the world of sense craving and
suffering (samsara) in favor for the pursuit of wisdom (prajna) leading to
freedom (nirvana).
Second Noble Truth. The Second Noble Truth traces the root of
suffering to one primary cause, that of misknowledge (avidya) regarding
the essence of self and phenomena; and to two secondary factors,
attachment and aversion. Human beings cling to experiences that by their
very nature must one day dissolve; and seek to avoid experiences that
inevitably arise. Individuals are driven by instinctual impulses because
they mistakenly believe that phenomena are essentially permanent, fixed,
autonomous, self-sufficient, and lasting. Insatiable thirst and fear-based
aversion propel people toward anguish, through a sequence of 12
interdependent factors of attitude, outlook, and behavior, variously
known as causal interdependence, conditioned genesis, or dependent origination
(pratityat-samupadda). Buddhist psychology systematically traces through
these 12 factors for a single root causes of suffering, variously identified as
fundamental ignorance, the delusion of separateness, self-alienation, the
defensive self-habit, self-cherishing and the reified self-habit (atmagraha)
(Loizzo 2000, 2004).
According to the theory of causal interdependence, human beings
control their mental and physical conditionsnot a theistic God or the
laws of external nature. This view explains that it is the mind that creates
26

all suffering, and it is the mind that has the ability to restore itself to peace
(Rahula, 1975). The conscious disarming of negative cognitive tendencies,
afflictive emotions, and unwholesome behavior removes the fuel and
extinguishes the fire of self-imposed suffering (Nyanaponika, 1965). In the
same way, recent stress research has revealed that the causal sequence of
events involved in the fight-flight responsenegative appraisal, adverse
emotions, and sympathetic activationcan be intentionally intervened,
regulated, and reversed (Appley, & Trumbull, 1986; Goldberger &
Breznitz, 1982; Loizzo, 2000). As a result, Buddhist psychology shifts the
blame as well as the responsibility of the human predicament away from
environmental influences (physical disease and mental illness) that
require external agents (i.e., doctors, therapists, medications, and/or
surgery) towards internal dynamics (cognitions, emotions, and habit
patterns) that require reflective analysis self-regulation and self-correction
(De Silva, 2000; Loizzo, 2006b).
Third Noble Truth. The Third Noble Truth posits the concept that
suffering can be eradicated. It is at this point that the Buddhist medical
model shifts from describing the nature and cause of suffering to
describing its alleviation. The focus of the Third Noble Truth is on the
elimination of compulsive behaviors (karma), unrealistic cognitive patterns
(samskara), and adverse emotions (klesha) through a systematic application
of behavioral discipline (sila), attentional control (samadhi), and reflective
learning. These paths lead to wisdom (prajna) and optimal states of health
and happiness, which lie beyond description in Western medical literature
(Goleman, 1977, 1979, 1981; Loizzo, 2000; B.A. Wallace, 2005). From this
27

perspective, individuals have the capacity to achieve a state of liberation

from craving and delusion known as nirvana (literally the extinction of
self-imposed suffering) and traditionally considered to be the full
flowering of human potential (Thurman, 1997).
Once behavioral compulsivity, emotional hindrances, and mental
obscurations have been removed, reality is said to have three
characteristics or qualities (trilaksana): impermanence (anicca),
dissatisfaction (dukkha), and the absence of enduring self-essence
(anatman). Individuals who are able to first intuitively conceive, then
directly perceive and finally live in accord with, the reality beyond their
misperception, are capable of dispelling disappointments, despair, and
even fear of death, and experiencing true happiness (U Pandita, 1991).
Here, Buddhist psychology differs from conventional theory in that it
offers extraordinary potential for total relief from suffering, rather than
mere symptom management or psychological adjustment (De Silva, 2000).
Fourth Noble Truth. The Fourth Noble Truth focuses on the path that
leads to freedom from self-binding compulsivity. As part of this plan,
Buddhist psychology prescribes the Eightfold Path, more eloquently
simplified by Loizzo (2004) as a reeducation program of three higher
trainings (adhisiksya). The curriculum involves ethical/behavioral
discipline (sila), mental concentration (samadhi), and wisdom (prajna) born
of experiential insight. Each of the higher trainings corresponds directly
with the three divisions of doctrinal canon (tripitaka): ethics with the
monastic code (vinaya), concentration with the sermons (sutra), and

28

wisdom with the psychological sciences (abhidharma) (Robinson &

Johnson, 1982).
The premise of the three higher trainings is to counteract the three
causes of suffering--desire, aversion, and misknowledge of the true nature
of the self and reality. In one Buddhist formulation (Nyanaponika, 1965)
hostility and aversion are counteracted by moral discipline and ethical
restraint. Desire, attachment, and clinging are subdued by the tranquility
of mind developed through concentrated stabilization; and the primary
impulse of narcissistic self-centeredness (atmagraha) is brought under the
sharp focus of meditative inquiry and logically refuted under analysis. As
a result of the application of these antidotes, individuals can reconstitute
their hyper-aroused and stress-addicted nervous system, adverse affective
conditioning, faulty cognitions, and maladaptive behavioral repertoire, by
invoking qualities such as, equanimity, humility, and altruism (Loizzo,
2004).
Freedom From Suffering
Selflessness. The Buddhas teaching of selflessness (anatman) is
unique among major world religions, philosophies, and psychological
systems (Fields, 1992). Insight into selflessness is the hallmark and
necessary prerequisite of the Buddhist path to health, happiness and
liberation (B.A. Wallace, 2005). Unfortunately, the concept of selflessness
is often misunderstood in the West and interpreted to mean that
fundamentally no self, soul, or ego exists (Epstein, 1995). What the
Buddha discovered was not that no self or soul exists, rather, that no fixed,
unchanging, nonrelative self exists. The Buddhas middle way teachings
29

of selflessness, avoids the two extremes of reifying a fixed self or denying

that a self exists at all. This teaching defiantly opposed the two
predominant worldviews in the Vedic culture of the Buddhas time,
including the dogmatic and authoritarian religious proclamation of an
essential unchanging soul (atman, jiva) and the materialist view of the self
as matter that dissolves into nothingness after death (Robinson & Johnson,
1982). According to one Buddhist view (Thurman, 1997) the self does
exist, as is a relative, insubstantial collection of aggregates (skandhas) in
constant flux and change, as a descriptive use of language, and as a mere
conventional designation. Watson (1998) points out that the Buddhist
tradition
makes a distinction between the mere self, the transactional self
which functions conventionally in the world, and a fictitious self,
an absolute or essential self which is to be denied. The general
definition of self rests on the term I, imputed in dependence
upon any and all five of the psychosomatic aggregates: material
form or appearance (rupa), and feelings (vedana), perceptions
(samjna), determinations (samskaras) and consciousness (vijnana).
The sense of self which we experience is compromised of these five
skandhas or aggregates, and it is the interplay of these rather than
any permanent partless ontological entity. From the Buddhist
point of view, ignorance or delusion arises when this process of
selfing is grasped at as an entity and identified with, rather than
experienced as an ever-changing expression of dynamic interaction.
In mindful awareness [practice] we can become aware of the
arising and falling, coming and going of discontinuous thoughts,
perceptions, feelings and sensations which make up what we like
to imagine as a single coherent and continuous self. (p. 96)
In terms of selflessness, suffering may be seen as a consequence of
attachment to a rigid sense of self, in which the latter is perceived as being
real, solid, and unchanging over time. Liberation and happiness are the
results of renouncing ones narcissistic self-cherishing and defensiveness
30

and expanding ones narrow self-identification past limited ego

boundaries to include a sense of interconnectedness, cherishing and
responsibility for all sentient beings (Loizzo, 2006b).
It is through mindfulness and insight meditation, that practitioners
are able to experience the intuitive realization of selflessness, by working
through the defilements (kleshas) and fundamental misknowledge (avidya)
(Nyanaponika, 1965, 1972, 1998; B.A. Wallace, 2005). Mindfulness
meditation thus has the potential to enable individuals to achieve the
wisdom of selflessnes and a state of liberation. A short excerpt from an
early Buddhist text, the Bahiya Sutta (Bs) found in the Udana (Ud), the third
book of the Kuddhanikaya (Kn), discusses the use of mindfulness
meditation to avoid identification with, and reification of, the aggregates
leading to freedom from suffering (nirvana). In this text, the Buddha
explained to his student Bahiya that
in reference to the seen, there will be only the seen. In reference to
the heard, only the heard. In reference to the sensed, only the
sensed. In reference to the cognized, only the cognized. That is
how, Bahiya, you should train yourself [in mindfulness]. When for
you there will be only the seen in reference to the seen, only the
heard in reference to the heard, only the sensed in reference to the
sensed, only the cognized in reference to the cognized, then,
Bahiya, you will not identify with it. When you will not identify
with it, you will not locate yourself within it. When you do not
locate within it, you are neither here nor yonder nor between the
two. This, just this, is the end of suffering. (Thanissaro and Access
to Insight, 1994)
Overcoming the defilements. According to the revered contemporary
Burmese Buddhist meditation master U Pandita (1991), there are three
types of defilements (kleshas in Skt, kilesas in Pali) that must be eradicated in
order for individuals to experience freedom from suffering (nirvana):
31

The first type involves defilement of transgression and includes

unwholesome and compulsive behaviors, such as killing, stealing, lying,
sexual misconduct, and the taking of intoxicants.
The second type of defilement involves more subtle obsessions,
cognitive ruminations that disturb ones mental equilibrium by
intensifying the secondary impulses of addictive clinging and repulsive
aversion. When transgressional defilements become preoccupations,
wishes, and fantasies, their power over individuals increases; because
thoughts are much more difficult to control than behavior.
The third type of defilement involves the dormant or latent tendencies
that operate only at an unconscious level. Within this level exist the
subtlest defilement, the root obsession or primary cause of suffering
known as the habit of self-reification (atmagraha) (Thurman, 1997) or the
defensive-self habit (Loizzo, 2004, 2006b). Dormant defilements manifest
as addictive or repellent mental propensities and consequent harmful
behavioral actions. They are deeply entrenched within a misinformed
perception of self in both its grandiose narcissistic presentation as well as
its hostile self-protective manifestation (Rubin, 1998). Because individuals
incorrectly believe themselves to be autonomous, fixed, and permanent,
they reify material reality in the same manner. In this way, they are
constantly involved in desirous clinging and fearful avoiding that go
against the ebb and flow of the true nature of reality (Loizzo, 2004, 2006b;
B.A. Wallace, 2005).

32

The Three Higher Trainings

According to U Panditas (1991) cogent systemization, in order for
individuals to subvert the power of the defilements, they must turn to the
antidotes of the three higher trainings:
If you are sincere in applying sila, samadhi, and panna, you can
overcome, extinguish and give up all three kinds of kilesas. Sila puts
aside the kilesas of transgression; samadhi suppresses the obsessive
ones; and wisdom uproots latent or dormant kilesas that are the
cause of the other two. As you practice in this way you can gain
new kinds of happiness. (p. 83)
Ethical Conduct (Sila). Sila is a branch of training designed to lessen
the attachments that individuals have to pleasurable experiences and the
avoidance they have to painful experiences. It is said that moral restraint
in action, speech, and livelihood leads to genuine delight and peace of
mind in a way that compulsive activity fails to provide. This is because a
balanced and realistic view of reality decreases ones continual
expectation and pursuit of pleasure and increases ones tolerance and
acceptance towards hardship, difficulty, and loss. Ethical conduct is based
on the nonharming of self and others. It is the fundamental practice that
targets overt behaviors and first-level defilements of transgression in
order to create a lifestyle conducive to the next set of trainings of selfreflection and meditation.
Attentional Control (Samadhi). Samadhi is the second training in the
system, and focuses on the internal mental defilements of unrestrained
compulsion and repulsion. The development of effort as well as skills in
concentration and mindfulness are used to counteract a regression
towards psychologycal states of automaticity and mindlessness, which
33

have recently become a subject of clinical interest (Kirsch & Lynn, 1999).
This phase of training works to reform and balance extremes in mental
disposition, such as dullness and laxity, restlessness and agitation,
attachment and avoidance, and clinging and hostility (B.A. Wallace, 1998,
2005a). According to U Pandita (1991) once the mind is well trained, it
becomes pliable, clear, even-keeled, and blissful (sukha) in order to be
utilized effectively in the last category of training, which is wisdom.
Wisdom (Prajna). The Sanskrit word prajna (Pali punna) translates as
wisdom and is the most essential and necessary cause of liberation
(nirvana). Wisdom is achieved, not through belief, but when refined
awareness (samadhi) is meditatively used to investigate, analyze, and
directly realize (vipassana) the nature of the self and of phenomena.
Training in the correct understanding and outlook of self and reality
works to carefully deconstruct and override ones powerful
misperceptions, the core of which is the aforementioned reification habit.
According to U Pandita (1991), only by progressing through the
meditative stages on the path of insight (to be reviewed later in this
chapter), can one learn to break free from the chains of misknowledge
(avidya) and be freed from the bondages of self-imposed suffering
(dukkah).
Buddhist Meditation Techniques and Topographies
The Buddhist path of self-healing and self-correction aims at the
cessation of suffering through the discursive and analytic uprooting of
defensive self-habits (Loizzo, 2004, 2006a, 2006b). The primary agent of
this process is bhavana, the Sanskrit term used to describe a wide range of
34

mind-body interventions used to cultivate the mind. In the West we have

translated the word to mean meditation, but this has the same descriptive
significance as the word sport does in the sense that there are numerous
variety of disciplines. Some practices aim at pacifying the mind and
quieting it from its usual state of afflictive distraction and confusion.
Other meditative techniques aim at the development of clear perception of
reality through the use of penetrative investigation. The Buddhist
tradition prescribes a combination of both methods (Goleman, 1977, 1979).
Buddhist meditation is divided into two types (B.A. Wallace, 2005):
(a) the concentration type, variously known as calm-abiding, quiescence,
or attentional control (Skt shamata, samadhi); and (b) the mindfulness type,
also known as bare-attention, witnessing, awareness training, insight
practice, or analytic insight (Skt, satipatanna, vipassana). Traditionally,
there are four postures in which to practice meditation: standing, walking,
lying down, and sitting. Meditation, therefore, can be incorporated into
any activity and is intended to become a mode of living (McDonald, 1984).
Seated meditation is the most common of these postures and is
composed of seven points: (a) a stable base involving a triangle of both
knees and the rear firmly planted on the ground and, with use of a
cushion, a tilting of the pelvis forward to enlarge the diaphragm area; (b)
the spine erect but not rigid; (c) hands placed in a specific gesture (mudra)
or relaxed on the lap; (d) the neck slightly tilted forward; (e) the tongue
gently rested on the roof of the mouth as not to produce excess saliva (and
swallowing); (f) the eyes may be shut if one is easily distracted or slightly
opened and lightly gazing at a spot about 2 feet in front if one is drowsy;
35

and, (g) gentle, unforced breathing through the nostrils. There are also a
series of guidelines on how to regulate attention depending on the style of
meditation (McDonald, 1984).
Concentration Meditation
Concentration is the common feature of all meditative practices
found throughout the history of the world, such as the Hindu yoga,
Jewish Kabala, Christian Gnosticism, Islamic Sufism, and indigenous
forms of shamanism (Goleman, 1977). Concentration meditation focuses
attention on one specific object, such as the breath, a word (mantra),
phrase, prayer, mental image, physical object, or thought. Whenever the
mind wanders away from this object, the meditator continually and
nonjudgmentally brings his awareness back to it. Concentration elicits the
relaxation response that counteracts the fight/flight stress response
(Benson, 1977).
Common physiological changes include decreased heart rate, blood
pressure, respiration, metabolism, and muscle tension. As concentration
strengthens, it is often accompanied by feelings of calmness, relaxation,
and equanimity and at advanced stages invokes experiences of bliss,
ecstasy, and absorption. The Buddhas instructions concerning
concentration are discussed in two texts found in the Pali Canon, the
Samadhi Sutta (Ss) (Thanissaro and Access to Insight, 1997b) and the
Anapanasait Sutta (As) (Thanissaro and Access to Insight, 2006). The
physical and psychological effects of concentration are well documented
by researchers in the field (Murphy & Donovan, 1999; D. H. Shapiro &
Walsh, 1984). Dunn et al. (1999) found that the health benefits attributed to
36

most concentration practices, such as decreased arousal, are shared by

mindfulness, while the specific benefits of mindfulness, learning and
deautomatization, cannot be replicated with concentration disciplines.
This distinction is useful in addressing the misconception that all
meditation practices are alike, even within the Buddhist repertoire.
There are many traditional maps that describe the effect of
concentration meditation on consciousness. They serve as useful guides to
the inner landscape for those embarking on the meditative journey; and
are the result of an ancient endeavor to systematize the diverse array of
experiences that occur during meditation. These systems can be extremely
valuable to Western researchers who have little knowledge of the function
and nature of mind at deeper levels of consciousness. While Western
maps have an outside-inside orientation, most Eastern maps, such as the
subtle body (chakra) system, orient the subject from the inside-out
(DeCharms, 1998). This is to assist meditative adepts in navigating their
own psychic terrain in vivo during meditative practice. It is this kind of
first-person empirical understanding of the depths of consciousness, as
well as the technology that accesses specific parts of the nervous system,
that distinguish meditative from conventional psychology (Varela &
Shear, 1999).
The Three Realms of Experience
Buddhism provides a series of internal maps to orient meditators
along a spectrum of consciousness as it is refined and developed
(Metzner, 1996). The first map discussed here is the Three Realms of
37

Experience (triloka); the second refers to the eight stages along the Path of
Concentration (dhyana). Both maps were recorded by the Buddhist sage
Buddhagosha (1991) in his pivotal 5th-century meditation manual, The Path
of Purification (Visuddhimagga) and subsequently adapted and reviewed by
Loizzo (2000, 2004) and Goleman (1988), respectively.
The first realm. The first realm of experience refers to waking
consciousness known as the desire realm (kamaloka), the everyday world of
sensual craving, addiction, afflictive emotions, and alienation, all of which
are rooted in the defensive self-habit. In this realm ones consciousness is
dominated by outwardly directed desire and fear-based aversion, which
results in the continual experience of dissatisfaction and disappointment
(dukkha). Loizzo (2000) correspond this state with the activation of the
neo-cortex, also referred to as the reptilian brain. Here the individual is
governed by the primitive instincts such as the pleasure principal, the will
to survive and the activation of flight-flight stress response.
The second realm. The second realm of experience is known as the
form realm (rupaloka), and is characterized exceptional states of
consciousness produces by quiescence or concentration meditation. The
Visuddhimagga indicates that form realms are when an individuals
consciousness becomes absorb in purified emotions (brahma viharas) such
as love, joy, compassion and equanimity. One may also gain access to
optimal cognitive capacities that correlate with Western notions of extra
sensory perception including clairaudience, the ability to hear sounds and
38

voices at a distance; clairvoyance, the ability to see events occurring in

remote places; retrocognition, the ability to recall past lives; and telepathy,
the ability to know the thoughts of others. Loizzo (2000) corresponds this
state to the activation of the limbic system, also known as the mammalian
brain, governed by the impulse of interconnectivity, social instincts and
the so-called love-growth response, which contrast with the fight-flight
protective mechanism.
The third realm. The third realm of experience is known as the
formless realm (arupaloka), in which the ultimate heights of nondual
absorptions are attained. Here subject and object, perceiver and perceived
are dissolved, along with notions of time and space. Experiences in the
formless realm represent the most refined and exceptional states of
concentrative meditation, culminating with samadhi, and corresponding to
the eighth and final stage on the path of concentration (dhyana). Loizzo
(2000) compares this state to the activation of the hypothalamus and brain
stem, and ephemeral experiences during deep sleep and orgasm.

The Path of Concentration

Stages 1 to 4 of Concentration (dhyana). Before actual concentrative
absorption commences, there is a transitional state of awareness known as
the access stage. This state of consciousness is traditionally considered to
be the most desirable for the practice of mindfulness meditation, because
the mind is unhindered by distracting sensatory-perceptual input, while
39

still retaining the discursive analytical capacities necessary for sustained

learning and growth.
The first level of concentration is characterized by the relinquishing
of desires and unwholesome factors (akushala), with the initial onset of the
dissolution of conceptualization (vitarka) and discursive thought (vichara).
This level is characterized by joyful interest (priti) and well-being (sukha).
The second level of concentration is characterized by the complete coming
to rest of conceptualization and discursive thought, the attainment of
inner calm, and one-pointedness of mind, achieved through concentration
on the object of meditation. Joyful interest and well-being continue. The
third level of concentration is characterized by joy that is subverted, and
replaced by equanimity; one is alert, aware and feels a sense of great wellbeing. On the fourth level of concentration, ones well-being is
transcended, leaving only equanimity and wakefulness to dominate
consciousness (Kohn, 1991). At this stage, the last of the dhyanas that
correspond to the form realm, psychic powers may be exhibited and
developed.
The latter four stages of concentration are (a) the absorption of
limitless space, which is beyond limited perception; (b) the absorption of
limitless consciousness, which is beyond undifferentiated subjectivity; (c)
the absorption of nothingness, which is complete subjective relinquishing;
and, (d) the peak of cyclic existence in which no course discrimination

40

exists at all, known as neither perception nor nonperception (samadhi).

These last four stages correspond to the formless realm.
While these increasingly subtle states of consciousness provide
temporary relief from suffering, produce pleasant and altruistic emotions,
and activate nondual perceptions, they are ultimately all within the realm
of conditioned existence (samsara). That is to say, while the mind can
achieve such advanced experiences of concentrative absorption,
individuals inevitably return to the base line normal waking state of
craving and dissatisfaction in the desire realm. For this reason it is
essential to develop the practice of mindfulness and analytic investigation,
in order to provide profound insight (prajna) and lasting transformations at
the base line level of waking consciousness. This type of Buddhist
cartography is useful in that it clearly identifies the higher capacities of the
mind, while providing landmarks for meditators to confidently traverse
the terrain of the inner landscape.
Mindfulness Meditation
The Pali word for mindfulness meditation satipatthana literally
translates as keeping present (patthana) awareness(sati). Mindfulness is
the second meditation technique in Buddhist psychology. This technique
differs from concentration in the way the attention is directed. Instead of
restricting attention to one object, attention is systematically expanded to
encompass any physical or mental activity from moment-to-moment with
an attitude of detachment and acceptance. Mindfulness encourages a
more exploratory and impartial stance towards whatever mind-object
presents itself in a given moment. It can be best understood at first as
41

being present without reacting, and at later stages in development as

analytically investigating what is being attended to.
Buddhist scholars (Sole-Leris, 1986; B.A. Wallace, 2005) have
pointed out that the Buddhas entire soteriology can be condensed to the
application of mindfulness mediation. In a famous sermon recorded in the
Satipattanna Sutta (Sp), the Buddha is reported to have said that, This is
the direct path, monks, for the purification of beings, for the overcoming
of sorrow and lamentation, for overcoming pain and grief, for reaching
the authentic path, for the realization of nirvananamely the four
applications of mindfulness(B.A. Wallace, 2005, p. 50).
At the access stage of consciousness, concentration and basic
mindfulness meditation are essentially the same meditation practice
because they both focus exclusively on the breath. As ones attention
expands to include more contents of consciousness, mindfulness departs
from concentration into distinct meditation practice.

Buddhist Instructions and Texts on Mindfulness

Various traditional Buddhist instructions and texts exist on how to
proceed with a mindfulness meditation practice (Bodhi, 1993; Gunaratana,
1991; Nhat Hanh, 1976; Nyanaponika, 1965, 1972, 1998; Sayadaw, 1972;
Soma, 1949; U Pandita, 1991; Silananda, 1990;). Most commonly in the
early Buddhist approach (Theravada) the mind is first well trained in
attention control (concentration) before beginning awareness training
(mindfulness) (Nyanaponika, 1965, 1972). Initially the mind is made
supple, malleable, and conducive to reflection as though it were a pond
42

whose ripples had been quelled, by using concentration to overcome the

five hindrances of restlessness, lethargy, sensual craving, malice, and
skepticism/doubt (B.A. Wallace, 2005).
Then the meditator uses skill in concentration to become absorbed
in a series of sublime affective states (bramha vihara), including rapture and
bliss (sukkha), loving-kindness (metta), compassion (karuna), empathetic joy
(mudita) and equanimity (uppeksha), which are used to counteract the
evolutionary force of the five major affective emotions (kleshas) namely:
greed, hatred, envy, anger, and fear (Goldstein & Kornfield, 1987). These
positive affective states prepare the mind for training in mindfulness
meditation where skill in concentration is conjoined with skills of
impartial observation and deconstructive analysis from which successes
levels of learning and insight are achieved (Loizzo, 2000, 2006b). Though
the aforementioned states of concentrative absorption and the sublime
states of positive emotion have their own therapeutic value, they need not
be fully actualized in order to embark on the path of insight (B.A. Wallace,
1998, 2005). The only requirement is for an individual to possess a
sufficient level of attentional focus and stability of mind, both of which are
known as access concentration. According to Goleman (1988),
The best level for practicing mindfulness is the lowest, that of
access. This is because mindfulness is applied to normal consciousness,
and from the first jhana on, these normal processes cease. A level of
concentration less than that of access, on the other hand, can be easily
overshadowed by wandering thoughts and lapses in mindfulness. At the
access level, there is a desirable balance: Perception of thought retain their
usual patterns, but concentration is powerful enough to keep the
meditators awareness from being diverted. . . . The moment of entry and
exit from jhana are especially ripe for practicing insight. (p. 21)

43

Another Buddhist approach, known as bare insight, prescribes the

use of mindfulness from the outset. This technique develops the necessary
skills of attentional control and refined awareness simultaneously rather
than sequentially. The practice also leads to the path of insight, although it
may take longer or initially require a higher degree of diligence to reach
access concentration (Sole-Leris, 1986).
Traditional instructions on the four foundations of mindfulness are
elaborated in the Pali Canon in two main texts, the Great Frames of
Reference (Maha-satipatanna Sutta) (Msp) (Thanissaro and Access to Insight,
2000) and the Frames of Reference (Satipatanna Sutta) (Sp) (Thanissaro and
Access to Insight, 1995). Modern commentaries on these texts are
available in The Four Foundations of Mindfulness (Silananda, 1990) and the
Analysis of the Frames of Reference (Satipatanna-vibangha Sutta) (Spv)
(Thanissaro and Access to Insight, 1997c). In general, one is instructed to
apply mindful awareness to: the body (namely, the breath),
feeling/sensation (pleasant, unpleasant, neutral), mind-state/emotions
(calm, agitated), and mind-objects/consciousness (mentality/thoughts).
As individuals develop their skills, they are led to detached observation
that uncouples the perceptual/cognitive dimension from the
emotional/affective response. This process is described as disidentification
with the object of perception, be it a thought, emotion or a sensation.
Once mindful observation is established, it is used for analytic
insight (vipassana), wherein disidentification takes place with regards to
the perception of self. Analytic insight meditation involves penetrative
investigation of the reifying self-habit, fosters relearning, and leads to
44

profound and sustainable insights, hense its name insight meditation

(Loizzo, 2006b; B.A. Wallace, 2005). According to U Pandita (1991) the
literal translation of the word vispassana is clear seeing (vi) the modes
(passana) or characteristics (trilakshana) of existence and refers to suffering,
impermanence, and selflessness. The difference between mindfulness and
analytic insight is an important distinction as the present study points out.
Note that basic mindfulness (satipatana) involves only bare attention of
mind/body events, while advanced mindfulness (typically referred to as
insight meditation) involves faculties of discursive thinking, investigation,
decision making, information processing, contemplation and analysis,
which are not typically associated with meditation practice (Loizzo, 2000;
B.A. Wallace, 2005). Mindfulness and insight are two phases in the
development of the same meditation practice, which was exclusively
developed by the Buddha, preserved in the classical tradition (Theravada),
and developed and refined in the Social Vehicle (Mahayana) and Adamantine
Vehicle (Vajrayana) (Goleman, 1988; Thurman, 1997).
The early Buddhist canon of scriptures (tripitaka) is divided into
three collections, the Moral Code (Vinaya-pitaka, Vp), the Discourses (Suttapitaka, Stp) and the Psychological Science (Skr Abhidharma-pitaka; Pali
Abhidhamma-pitaka, Ap). The seven volumes of the Abhidhamma-pitaka,
offer an extraordinarily detailed analysis of the basic natural principles
that govern mental and physical processes. Whereas the Sutta-pitaka and
Vinaya-pitaka lay out the practical aspects of the Buddhist path to
awakening such as behavioral conduct, the Abhidhamma-pitaka provides a
theoretical framework to explain the causal underpinnings of that very
45

path. For modern commentaries on the Abhidhamma one is directed to

Bodhi (1993) and Nyanaponika (1998).
In Abhidhamma psychology the familiar psycho-physical universe is
distilled to its essence revealing an intricate web of impersonal
phenomena and processes unfolding at an inconceivably rapid pace from
moment-to-moment, according to precisely defined natural laws of causal
interdependence (pratiyatsammutpada). The Abhidhamma details the manner
in which mental phenomena are thoroughly examined, using mindfulness
and analytic investigation (Thurman, 1984). The literature concerning the
theory and practice of traditional Buddhist mindfulness meditation is
extensive with numerous studies by Western researchers (Bucknell &
Kang, 1997; Goldstein, 1994; Goldstein & Kornfield, 1987; Goleman, 1988;
Loizzo, 2006b; Sole-Leris, 1986; B.A. Wallace, 1998, 2005), as well as
various classical presentations by Asian Buddhist Masters (Gunaratana,
1991; Nhat Hanh, 1976; Nyanaponika, 1965, 1972, 1998; Sayadaw, 1972;
Soma, 1949; U Pandita, 1991; Silananda, 1990).

The Path of Insight

There are several Buddhist maps that detail the psychological
developments produced by mindfulness along what is called the Path of
Insight. Goleman (1988) provides a lengthy discussion of subjective
realizations using an eight-stage model; U Pandita (1991) condenses this
same model to four stages focusing exclusively on the eradication of
particular defilements (kleshas). Sole-Leris (1986) discusses the
characteristics of the advanced levels of consciousness developed by four
46

types of meditative adepts known as, the stream enterer (sotapanna), the once
returner (sakadagami), the nonreturner (anagami), and the liberated saint (Skt
arhat; Pali arhant) who are successively closer to achieving enlightenment.
These three authors rely on Nanamolis translation of Buddhagoshas (1991)
The Path of Purification (Visuddhimagga). For a contemporary and userfriendly commentary of this classic manual, one is directed to Flickstein
(2001). In contrast, other Western scholars (Loizzo 2000, 2006b; Thurman,
1984) rely on De La Vallee Poussin and Pruden translation of Vasubandhus
(1988) The Treasury of the Psychological Sciences (Abhidharmakoshabysham) as
an alternative 5th-century Indian meditation manual. These scholars find
the later text more comprehensive and refined because it traces the
development of insight beyond the stages of individual liberation
(Theravada) to the more generous aim of social consciousness and
universal responsibility prescribed in the Social Vehicle (Mahayana).
Insight Stages 1 and 2. Golemans (1988) representation of the early
texts begins with the attainment of stage one, access concentration, which is
characterized by attentional stability and receptive awareness. In
achieving this ability, individuals find that they are not distracted by, or
attached to, stimuli during meditation. In the second stage, mindfulness,
one formally applies these qualities of receptivity and stability to the
observation of four foci namely, body, physical sensations, mental states
and mind objects. In the third stage, reflection, the first experience of
insight occurs in which one gains an inference into the three
characteristics of reality (trilakshana) (selflessness, impermanence, and
dissatisfaction). Primary among these characteristics is an understanding
47

of selflessness (anatman), the idea that no fixed agent controls the stream of
thought and that no independent, automaton is at the center of ones will
and experience.
According to Rahula (1975), an exhaustive analysis of the five
aggregates or life systems that appear to constitute a person (Skt skhandas;
Pali pancakkhandhas), including material form (rupa), sensations (vedana),
perceptions (sannak), mental formations (samkhara), and consciousness
(vinnana), reveals no enduring, unchanging self-referent. Similarly,
according to Capra (2000), a reductive analysis of external phenomena
down to the atomic nuclei level reveals no essential, permanent,
nonrelative core, an insight that substantiates the ancient Buddhist notion
of subjective and objective selflessness (anatman/shunyata).
Insight Stage 3. Next, mindful observation reveals the temporal and
continually changing nature of all thoughts, emotions, sensations, and
bodily functions, which deepens ones understanding of a second
characteristic of phenomena impermanence (annica). Based on these two
inferences, the realization arises that an identity and world, misperceived
as stable and enduring, can only bring misery, frustration and
disappointment. Such an awareness constitutes the third mark of
existence, dissatisfaction (dukkha), resulting from attachment to compulsive
and mindless living (samsara). The insight attained at the third stage on the
path is said to inspire great renunciation. Rather than a passive
reconciliation to a terminal fate (nihilism), or a turning over to the will of
an external power (theism), the Buddhist insight into dukkha increases the
motivation and ability of individuals to detach themselves from the causes
48

and conditions that give rise to dissatisfaction and misery, and work
diligently to discover the causes and conditions that constitute a life of
happiness and freedom.
Insight Stage 4. In the fourth stage, pseudonirvana, the clear and
continued perception of the arising and passing of mental phenomena,
including ones projections and misperceptions, leads to a false sense of
relief. An experience of enjoyment and even celebration begins to set in
because individuals believe that, by disengaging from habitual mental
processes, they have achieved true cessation (nirvana). While there has been
a powerful and radical breakthrough, it remains only a course inference,
what U Pandita (1991) calls deductive knowledge, which leaves the
primal unconscious and latent defilement prone to seeing this new view
of reality as concretely and inherently real. Exacerbating the situation, a
mind at this state is said to experience the ten corruptions or fetters, such
as expansive and rapturous feelings, tranquility, intense devotion, energy,
and happiness, which are themselves reified and become the source of
attachment and clinging. It is only through working with a qualified master
(guru, kalyanamitra) that the meditators realize their premature error and
turn their mindfulness back on itself so that they can dissolve the more
subtle defilements of attachment and reification, and progress along the
path.
Insight Stage 5. Once the above has been achieved, the fifth stage of
realization, presents itself. Here instead of a false sense of relief, the
meditator is gripped by fear. With the doors of perception thus cleansed,
permitting one to see the arising, sustaining and passing of mental
49

phenomenon without attachment, the thought arises that everything is

baseless and void. As Goleman (1988) states,
The slightest awareness [the meditator] sees as utterly destitute of
any possible satisfaction. In them there is nothing but danger. The
meditator comes to feel that in all kinds of becoming there is not a
single thing that he can place his hopes on or hold onto. (p. 28).
Once again in consultation with the expert teacher, the meditator is asked
to mindfully observe the emergence of the primal need for the security of
the reified self. Fear is then seen as the by-product of remaining attached
to a vulnerable self that has been debased. The three qualities of existence
(trilaksana) must be revisited with deeper meditation and analysis in order
to transform the fear of the selfless void into an intuitive insight; or
wisdom (prajna) that perceives interconnectivity (pratityatsamutpadda) (U
Pandita, 1991) and ultimately the bliss and opportunity of a fluid reality
(shunyata) (Thurman, 1998).
Insight Stage 6 and 7. The sixth stage, effortless insight, marks this
transformation in which fear is supplanted by confidence born of
experience. Meditators now achieve a natural and graceful ease of
reflection that continues to reinforce their understanding of selflessness
(anatman) and the middle way, which avoids clinging and aversion,
pleasure and pain, enjoyment and terror. In the seventh stage, nirvana, the
self-reifying habit is finally dissolved and the future causes of suffering
eradicated. Whereas aspects of greed, hatred, and delusion were
suppressed by the higher states of consciousness only to emerge again
later during waking consciousness on the concentrative path of
tranquility, on the path of insight, waking consciousness itself has been
purified and transformed. What occurs with the realization of selflessness
50

and the achievement of liberation is an enduring change in personality

rather than a temporary state of pleasant experiences.
While cogent definitions of liberation (nirvana) are rare, Makransky
(1997) stated that, precise philosophical formulations of nirvana varied
between Abhidharma schools, but in its primary description, nirvana
represented the cessation (nirodha-satya) of karma [actions] and klesha
[defilements/afflictive emotions] that give rise to the cycle of rebirth [and
suffering] (p. 28). Despite the eradication of causal conditions,
enlightened beings still experience the residual effect (sopadhisesa) of their
past evolutionary stream of consciousness. The analogy of a steam train is
useful here, in which coal is no longer added to propel the engine, but the
train remains in motion until its momentum fully ceases.
Insight Stage 8. The eighth and final stage in Golemans (1988)
representational map of early writings is known as complete cessation
(nirodh). When the remaining residual imprints have taken their effect and
become exhausted, the stream of consciousness is then bound only by the
human body. According to Makransky (1997),
The arhats [saints] body, and the mental component associated
with it, [themselves] comprise a residuum of conditioned existence
(caused by the actions and passions of past lives) that will continue
to his physical death. But upon his physical death, because the root
cause of future conditioned existence has been utterly removed, the
arhat [saint] is said to pass into a state permanently free from
further rebirth: nirupadhisesa nirvana, nirvana beyond any further
residual conditioning. (p. 28)
The question then arises, what happens to the consciousness of
enlightened beings after death? Does it disappear when electrical
impulses in the brain no longer function, as science predicts? Or does it
51

continue to abide beyond the world in an absolute and permanent realm

as many religious institutions have proclaimed? The standard Buddhist
middle way response avoids either answer, suggesting that such a
consciousness remains in the world but is no longer bound by the
conditions of samsara (Makransky, 1997). Thurman (1998) described the
Buddha as an enlightened being who abandoned all ordinary roles and
created a new one in which an individual lives in the world but not of
the world, who connects himself and therefore others to a transcendent
reality that puts the demand of relative reality into the context of the
transcendence (p. 93).
According to Golemans (1988) discussion of the classical
Theravada source the Visuddhimagga (Buddhagosha, 1991), the purified
consciousness realized in nirodh does not cease to exist after the final death
(parinibbana); rather it only ceases to exist under the ordinary laws of
causality that govern the realm of suffering (samsara). Goleman (1988)
points out that the liberated mind developed on the path of insight is then
reapplied to the concentrative path of tranquility in its eight successive
levels. Combining skills in stabilization and insight into selflessness, the
enlightened individual advances through, and abides indefinitely within,
all three realms of existence (triloka), the desire realm, the form realm, and
the formless realm, in order to be a more efficacious advocate for liberation
for other sentient beings.
In the messianic or Greater Vehicle tradition (Mahayana), motivated
by universal compassion (mahakaruna) a Buddha is said to take rebirth in
forms of its choosing and remains active in all world realms in order to
52

assist others beings in their pursuit of liberation (Patrul, 1998). According

to the Mahayana view of nondual relativity (shunyata), nirvana is not
conceived of as an absolute realm beyond samsara, thus the Buddha
remains within the suffering world, with a purified perception that reenvisions it as sheer bliss (Thurman, 1998). With such perceptual
flexibility, vast new realities and heavenly realms (pure lands) are
conceived and actualized by the altruistic and creative potential of the
fully enlightened Buddha (samyaksambuddha) in order to provide maximally
effective environments in which to train enlightened heroes (bodhisattvas)
and facilitate the development of less realized individuals who are on
their path to Buddhahood (Kalu, 1997; Makransky, 1997; Patrul, 1998; P.
Williams, 1989).
Summary
In the present chapter, it can be seen that Buddhism, contrary to
popular belief, is more than an Asian religion, but a psychological
tradition that offers individuals precise and sophisticated methods of selfreflection and self-correction aimed at achieving health and happiness
(Loizzo, 2006b).
The basis of Buddhism is grouped under the Four Noble Truths, a
medical model that delineates the diagnosis, etiology, prognosis and
treatment of suffering. The treatment is further subdivided into the three
higher trainings (adhisiksya) of ethics, meditation, and wisdom, which
collectively work to dissolve attachment, aversion and self-reification at
the root of human dissatisfaction. The research has shown that the
wisdom of selflessness is the most salient and indispensable notion of
53

early Buddhism, and any references to the effects and benefits of the
Buddhist practice of mindfulness meditation without it are simply
incomplete and insufficient. The literature and research regarding the
psychological effects of mindfulness and its use in the treatment of
medical conditions in the West will be addressed next.

54

CHAPTER 4: MINDFULNESS MEDITATION IN MIND/BODY

MEDICINE
Towards a Science of Enlightenment
There are currently few scientific attempts to examine the concept
of enlightenment and other radical shifts in consciousness produced by
meditation, although there have been some preliminary efforts
particularly in the field of neuroscience (DAquili & Newberg, 1999;
Ekman, Davidson, Ricard, & B.A. Wallace, 2005; Lutz, Greischar,
Rawlings, Richard, & Davidson, 2004; Newberg & DAquili, 2001;
Newberg et al., 2001; Tart, 2003; B.A. Wallace, 2003). Reasons vary for the
lack of empirical research on these subjects. Findings from several reports
(Tart, 1972, 1975; Varela & Shear 1999; Varela, Thompson, & Roach, 1991)
indicate that
1. Scientists may be limited by a lack of linguistic or conceptual
frameworks needed to understand advanced altered states of
consciousness, as there is currently no coherent understanding
of consciousness in the West.
2. Scientists holding rigidly or dogmatically to their own
fundamentally materialistic (nihilistic) paradigm of reality may
not consider the paradigm of prescientific, mystical, or religious
traditions.
3. There are too few adept meditation practitioners willing to
serve as appropriate subjects of scientific investigation as this
may conflict with their values or traditions of verification.

55

4. The very nature of an objective, reductionistic, or mechanistic

study of consciousness may alter the subject and/or process
that is being observed.
5. The current Western methods of investigation are as yet
insufficient or inadequate to measure altered states of
consciousness with any reliability.
As a result of these and other limitations, mainstream science has
typically dismissed meditation and claims of enlightenment as
speculative, nonrational and as an unworthy subjects of empirical
research (Loizzo & Blackhall, 1998).
The Buddhist literature presents the enlightened state of
consciousness as an individuals optimal evolutionary development,
prescribing a highly refined curriculum and sophisticated technologies to
achieve this goal. Furthermore, it views advances in states of
consciousness as a phenomenon that can be reliably tested and verified by
meditative experts and adepts with the use of a standardized, objective
quasi-scientific method. Within the relatively neutral framework of logic
in ancient India, a system of validation known as valid cognition
(pramana) was employed to scrutinize the reliability of truth claims put
forth by competing philosophical school. In his seminal book on the
ancient Indian Buddhist logician Dharmakirti, Dryfus (1997) contends that
the pramana method provides a standard of validationindependent of
religious or ideological backgroundsthat is useful for assessing the
reliability of mental events.

56

The Buddhist epistemological method of valid cognition relies on

subjective-objectivity (Thurman, 1998; B.A. Wallace, 2003) also known as
first-person objectivity (Varela & Shear, 1999), which contrasts with
conventional scientific objectivity because it permits and encourages the
use of highly trained, sustained, and nonjudgmental subjective awareness
to examine internal states and experience. B.A. Wallace (2003), a Buddhist
scholar and scientist, challenged critics who discredited the Buddhist
proposition of enlightenment, based on their assumption that the subject
fell outside the purview of the currently accepted scientific model of
consciousness.
B.A. Wallace (2003), in agreement with D. Chalmers (1995), argued
that to date Western science had no definitive description or
comprehensive understanding of consciousness, and should therefore
critically examine the extensive findings achieved by contemplatives of
other traditions over the course of the millennia. B.A. Wallace (2003) also
reminded skeptics that Buddhism was not a religion that relied on faith,
but was an ancient spiritual tradition that aimed to understand reality and
the nature of consciousness through direct observation, examination, and
replication, and was thus more consistent with current scientific methods.
Finally, he argued that any hypothesis, including those proposing the
possibility of enlightenment or reincarnation, deserved to be critically
evaluated with all empirical and rational means available, without
invoking the authority of any religious texts or metaphysical principles
that might bias such an investigation.

57

According to B.A. Wallace (2003), scientific inquiry demands that

any reality claim must be meticulously scrutinized before being
dismissed, otherwise how could its validity be actually known? By
remaining objective and examining all possibilities, researchers can
remain consistent with the Buddhas own recommendation to come and see
(Pali: ehi-passika) his teachings rather than believe them out of faith or
duty. As the Buddha says in one of his discourses, As the wise test gold
by burning, cutting and rubbing it, so, bhikshus [monks], should you
accept my wordsafter testing them, and not merely out of respect."
(Rahula, 1975, p. 9)
Speaking like a scientist, His Holiness the Dalai Lama, spiritual and
cultural leader of the Tibetan exiled community, made the following
remarks concerning the Western scientific method and the Buddhist
epistemological method:
From the methodological perspective, both traditions emphasize
the role of empiricism. For example, in the Buddhist investigative
tradition, between the three recognized sources of knowledge,
experience, reason and testimony, it is the evidence of the
experience that takes precedence, with reason coming second and
testimony last. This means that, in the Buddhist investigation of
reality, at least in principle, empirical evidence should triumph
over scriptural authority, no matter how deeply venerated a
scripture may be. Even in the case of knowledge derived through
reason or inference, its validity must derive ultimately from some
observed facts of experience. Because of this methodological
standpoint, I have often remarked to my Buddhist colleagues that
the empirically verified insights of modern cosmology and
astronomy must compel us now to modify, or in some cases reject,
many aspects of traditional cosmology as found in ancient
Buddhist texts.
(Gyatso, 2005, para. 4)

58

Thurman (1991) similarly argued that it would be a disservice to

Western health care professionals to dismiss Buddhist psychologys claim
to enlightenment, because such an examination of an alternative paradigm
might help them to develop their own psychological methodology, which
is still in its infancy. Furthermore, he encouraged Western researchers to
suspend judgment and criticism, and to expand the limits of possibility
when it came to the concept of enlightenment, as it was in his view, not so
obscure or impossible. Elsewhere, Thurman (1998) pointed out that
hundreds of Tibetan practitioners (yogis) in modern times, prior to the
invasion of China in the 1950s, achieved this optimal state partly because
of the spiritually conducive environment and teaching context that their
countrys sociopolitical system provided. In agreement with B.A. Wallace
(2003), Thurman (1998) encouraged researchers to maintain their unbiased
scientific stance of objectivity and inquisitiveness, even if it was imbued
with healthy skepticism:
No matter how preposterous it may seem at first, it is necessary to
acknowledge the Buddhas claim of the attainment of omniscience
in enlightenment. . . . It is rarely brought to the fore nowadays,
even by Buddhist writers, since this claim by a being once human is
an uttermost, damnable sacrilege for traditional theists and a
primary fantasy, an utter impossibility, for modern materialists
[scientists]. But it is indispensable for Buddhists. A Buddha is
believed to have evolved to a state of knowing everything
knowable, evolving out of the states of ignorance of the limited and
imperfect awareness of animals, humans and gods. Therefore the
purpose of ones own life, seen as a process of infinite evolution, is
to awaken such omniscient awareness within oneself, to transcend
the ego centered animal condition to become a perfect Buddha. (p.
10)

59

The History of Clinical Meditation Research

In the United States, clinical research into meditation began
approximately 50 years ago. Primarily motivated by interest in the ancient
practices popular in the cultural mainstream, the medical community has
sought to determine their effects and possible health benefits. At the same
time, evidence-based research into meditation has not been without
resistance and opposition. On one side, the spiritual community argues
that an objective study of meditation forces it to be removed from its
natural context (as when the meditator is hooked up to various measuring
devices), thereby altering or corrupting the experience (Hirst, 2003). And
on the other, there are those within the scientific community who
exclusively associate meditation with religion and find it an unworthy
subject for experimental research. Essentially, this debate represents more
than a difference in methodological style: it represents a clash of
worldviews and epistemologies (Tart, 1972).
As DeCharms (1998) clearly established, there are several
significant differences between Buddhist meditative psychology and
Western physical science, differences which indeed make their
comparison even more interesting and valuable. According to the author,
the most obvious is the fact that the objective of meditation is to
understand the causal mechanism (pratitya-samupadda) of human
experience in order to recondition habits and achieve existential freedom
(nirvana). The purpose of science is to understand the laws of physical
reality in order to exercise control over external phenomena.

60

A more subtle difference is revealed when comparing the way in

which objectivity is treated. Physical science uses objective reductionistic
analysis to describe mental processes in mechanistic terms from an
external perspective. Meditative science, on the other hand, uses
subjective-objectivity to describe mental processes in experiential terms
from an internal perspective. As can be seen, each of these systems has its
own descriptive language as well as a precise and rigorous analysis of the
same mental phenomena. In meditation, the emphasis is on the
determination of what is manifested internally, whereas with science often
the measure is focused on external forces and pressures.
Despite these differences in approach and method, the initial
hesitancy and skepticism concerning the study of meditation have slowly
begun to subside. This is due partially to the fact that cross-cultural
research (DeCharms, 1998; Gyatso, 1997; Gyatso et al., 1991; Varela et al.,
1991) reveals that both disciplines are not mutually exclusive, but are
rather complementaryeach may fill in the theoretical and practical gaps
that the other system ignores. The results of such findings are slowly
reshaping our current scientific paradigm. According to Taylor (Murphy
& Donovan, 1999)
Certain changes are currently underway within the basic sciences
that presage not only further evolution of the scientific method but
also a change in the way science is viewed in modern culture. An
unprecedented new era of interdisciplinary communication within
the subfields of the natural science, a fundamental shift from
physics to biology, and the cognitive neuroscience revolution have
liberalized attitudes towards the study of meditation and related
subjects. (p. 10)

61

The earliest and most prolific research (in terms of the number of
published studies) focused on the investigation of Transcendental
Meditation (TM), a secular, concentrative style of mental practice
introduced to the West in the late 1960s by the Vedantic teacher,
Maharishi Mahesh Yogi (Hjelle, 1974). Between the 1970s and the 1990s,
an extensive research initiative led by Orme-Johnson (Chalmers,
Clements, Schenkluhn, & Weinless, 1989a, 1989b, 1989c; Fehr, 1977; OrmeJohnson and Farrow, 1977) at Maharishi International University
produced a vast data bank of some 508 studies reporting on the
physiological, psychological, sociological, and theoretical effects of TM.
The five-volume report contained evidence supporting a possible
hypometabolic fourth state of consciousness beyond the usual waking,
dream, and deep sleep states. It also showed a reduction of medical
conditions such as asthma, angina, and high blood pressure as well as an
increase in personality variables such as problem solving, creativity, selfesteem, field independence, and self-actualization. Finally, the research
project initiated a preliminary study on the effects of TM on psychiatric
and behavioral disorders, and on biomedical and endocrinological
measures (Wallace, 1970; Wallace & Benson, 1972; Wallace, Benson, &
Wilson, 1971).
These preliminary findings on TM were then followed up by
another major research initiative headed by Herbert Benson (1972, 1975) a
cardiologist at Harvard Medical School, who later broke new ground by
investigating advanced Buddhist practices (gTummo), although he
neglected to explore their philosophical underpinning (Benson, Lehmann,
62

et al., 1982). Recorded on sight in the subzero degree Himalayas, Benson

and colleagues studied Tibetan monks who, through controlling
autonomic processes, were able to voluntarily generate enough body heat
to produce steam and eventually dry wet sheets draped around their
naked bodies. While they documented the remarkable physiological feat
of the monks, Benson, Lehman, et al. (1982) failed to recognize the
purpose of their practices, which was to gather and purify the passionate
(sexual and aggressive) energies of the subtle body (chakra) and redirect
them towards the dissolution of egocentricity, fear of death, and
misperception of reality (Thurman, 1991).
Nevertheless, Benson and his colleagues played a significant role in
confirming the mind/body relationship by expanding Western medicine
beyond limited Cartesian assumptions. By extrapolating fundamental
techniques common to both TM and basic Buddhist meditation, such as
quiet breath observation with a passive nonjudging attitude, Benson
(1975) created a patient friendly style of practice, which he termed the
relaxation response to be applied in medical settings.
Clinical studies suggest that the Herbert Bensons (1975) relaxation
response is effective in reversing fight-flight response patterns, lowering
hypertension, headache, alcohol consumption, heart disease, and serum
levels as well as being effective with psychiatric disorders such as anxiety
(Benson, 1992, 1996; Benson & Wallace, 1972). Bensons (1972, 1977) main
contribution is the methodologically sound nature of his research, and his
publications in both medical journals and popular books have succeeded
in promoting self-healing techniques as viable adjuncts to surgery and
63

pharmacology. In conjunction with Beth Israel Deaconess Medical Center

and the Harvard Medical School, he launched the Mind/Body Medical
Institute, a for-profit research and training program in behavioral
medicine. The institute conducts research on, and provides instruction
for, the medical application of meditation.
Another major program in the scientific study of meditation
continues under the direction of Jon Kabat-Zinn at the Center for
Mindfulness in the Department of Medicine, Division of Preventative and
Behavioral Medicine, at the University of Massachusetts Medical Center.
Kabat-Zinns program is more explicit in its use of Buddhist mindfulness
practice, in contrast to Bensons (1992) program, which employs only
secularized concentrative forms of meditation. Kabat-Zinns (1982, 1990,
1994) research, like Bensons (1992, 1996), indicates that Buddhist
mindfulness meditation may produce similar decreases in symptoms of
heart disease, cancer, chronic pain, irritable bowl syndrome, infertility,
insomnia, headache, HIV, and AIDS as well as other disorders of stress
and anxiety. This is because both Bensons (1975) method and Buddhist
mindfulness practice elicit the physiological relaxation response.
In addition, mindfulness meditation has been found to provide
health benefits, which distinguish it from other meditative disciplines
(Kabat-Zinn, 1990). Kabat-Zinn and his colleagues have developed a
reproducible curriculum in health education and stress reduction known
as Mindfulness-Based Stress Reduction (MBSR), which has gained
considerable success and is held in high repute. MBSR is utilized in over
200 affiliate centers throughout North America, and serves as a prototype
64

for subsequent developments integrating mindfulness meditation and

psychotherapy, DBT (Linehan, 1993b), Acceptance and Commitment
Therapy (ACT) (Hayes, Strosahl, et al., 1999), and MBCT (Segal et al.,
2002).

The Physiological Effects of Mindfulness Meditation

While meditation is primarily an attentional discipline designed to
establish control over automatic thought patterns and negative affective
responses, the physiological dimensions of the practice have received the
most attention by health researchers. To date, studies determining the
physiological effects of meditation far outweigh all other areas of inquiry
in the medical literature. This is due primarily to the fact that, in most
cases, physical measurements are accessible, easily recorded, and
consistent with reductionistic Cartesian assumptions about the body.
Research in this area began with an investigation of some of the
more extraordinary feats of physiological control performed by advanced
yogis in India during the 1920s and 1930s, as well as studies of Zen
Buddhist monks in Japan during the 1960s. Das and Gastaut (1955),
Anand and Chhina (1961), and Wegner and Bagchi (1961) discovered that
advanced yogis practicing concentrative absorption could intentionally
stop their heart beats and remain buried underground for extended
periods of timein one case for 8 days (Kothari, Bordia, & Gupta, 1973).
These studies involved the measuring of brain waves, heart rate,
oxygen consumption, skin resistance, and blood pressure. Through
extensive EEG monitoring, Kasamatsu et al. (1957) and Hirai (1960) found
65

that advanced Zen practitioners using open-focus zazen meditation

maintained exceptional degrees of moment-to-moment awareness of both
internal and external stimuli. These studies highlighted the difference
between the two main types of meditation practice: concentration with a
narrow or one-pointed attentional focus, and mindfulness with a wide or
open attentional focus. Furthermore, these studies were groundbreaking
because they provided the first concrete evidence that previously
inconceivable, even miraculous, feats of autonomic, respiratory, and
perceptual control were possible through self-regulatory strategies
(Murphy & Donovan, 1999; D. H. Shapiro & Walsh, 1984).
In subsequent years, research in clinical settings has been
conducted to see how different physiologic functions are affected by less
adept meditation practitioners. Many findings support the hypothesis that
mindful meditation directly reduces every major category of the fight-orflight response, decreasing the harmful effects of stress, and possibly
preventing the occurrence of major or even fatal stress-related illnesses.
The present chapter discusses the most current reviews of the literature
(Murphy & Donovan, 1999; D. H. Shapiro & Walsh, 1984), with particular
focus on the methodologically sound studies conducted by Benson (1972,
1977), the effects of meditation on the heart, blood pressure, metabolism,
respiratory system, and muscle tension.
The Cardiovascular System and Disease
The literature indicates that meditation has different cardiovascular
effects depending on the type of practice. Those practices having an active
component, such as tantric visualization, devotional chanting, and
66

concentrative styles leading to ecstatic states, tend to increase heart rate;

while those practices that are passive, such as TM, Bensons relaxation,
and Buddhist mindfulness, generally lead to decreased heart rate.
Furthermore, some studies suggest that the decrease of beats per minute
as well as the duration of the decrease is proportionate to the level of
experience of the adept. For example, Wallace and Bensons (1972) study
suggests that for an average clinical patient, the heart rate can decrease by
as many as three to five beats per minute during TM. These results were
confirmed by at least three other studies in the literature (Murphy &
Donovan, 1999).
Other important observations are made by Bono (1984) who found
that the reduction in heart rates recorded during TM practice was greater
than those resulting from quietly sitting with eyes closed. Delmonte
(1984b) similarly found that for 52 subjects, heart rates were slightly lower
during meditation than they were at rest. These findings contradicted
those of Smith (1975) who maintained that the effects of meditation might
be similarly produced by the expectation of relief or by simply sitting
quietly.
There is increasing agreement in the literature that meditation may
have potential in relieving certain forms of cardiovascular disease, as well
as reducing stressful impacts and chronic or inappropriate activations of
emergency responses (Glueck & Stroble, 1975, 1984). Specifically, studies,
including Benson and Wallace (1972), Benson (1976), Cooper and Aygen
(1979), and Barr and Benson (1984), report significant reductions of

67

hypercholesterolemia and angina pectoris through the use of relaxation

and TM.
Perhaps the most revealing study comes from Ornish et al. (1990)
who used a prospective, randomized, controlled trial to determine
whether comprehensive lifestyle changes affected coronary
atherosclerosis. 28 patients were assigned to an experimental group whose
varied lifestyle modifications, partially based on Indian Ayurvedic
medicine, included a low-fat vegetarian diet, smoking cessation, moderate
exercise, and a combination of relaxation, meditation, and yoga. The
control group consisted of 20 patients who were assigned to the usual-care
regimen. After one year 195 coronary artery lesions were analyzed by
quantitative coronary angiography. For the experimental group, the
average percentage diameter stenosis regressed from 40.0 (SD 16.9%) to
37.8 (SD 16.5%), in contrast to the usual-care group whose stenosis
progressed from 42.7 (SD 15.5%) to 46.1 (SD 18.5%). According to the
study, analysis of lesions greater than 50% stenosed revealed that the
average percentage diameter stenosed regressed from 61.1 (8.8%) to 55.8
(11.0%) in the experimental group; and progressed from 61.7 (9.5%) to 64.4
(16.3%) in the control group.
Overall, Ornish et al. (1990) reported that 82% of the experimental
patients had an average change towards regression, and concluded that
comprehensive lifestyle change might bring about regression of even the
most severe coronary atherosclerosis after only one year, without the use
of lipid-lowering drugs. This is significant because at best most
conventional treatments only slow down or temporarily arrest the
68

progression of stenosis, whereas the comprehensive lifestyle treatment

actually reversed stenosis in the experimental group. The fact that
meditation and yoga were not isolated from other factors in the
experimental group was not considered problematic by the authors
because traditional Indian and Buddhist healing techniques usually
involved a holistic multimodal treatment plan, which combine diet and
physical exercises with mental training. From a scientific perspective, the
dramatic result cannot be isolated to the effect of meditation alone.
What becomes apparent from this study is the difference in
approach. Conventional Western medicine focuses exclusively on
mechanistically affecting the diseased portion of the body, while Indian
approaches attempt to regulate various interconnected lifestyle factors
underlying the disease. Ornish et al. (1990, 1998) followed up this study
and supported their initial findings. The researchers brought greater
awareness to the public regarding noninvasive treatment alternatives, the
powerful influence of the mind and emotions to heal the body, and the
importance of long term lifestyle changes (Gould et al., 1995).

69

Blood Pressure and Hypertension

There is strong evidence in the medical literature that meditation
helps lower blood pressure in patients who are normotensive or
moderately hypertensive. Murphy and Donovan (1998) indicated that as
many as 19 studies replicated these findings, some of which observed
significant systolic reductions in patients of 25 millimetres of mercury
(mmHg) or more. They further showed that meditation decreased blood
pressure as a result of the
relaxation of large muscle groups pressing on the circulatory
system in various parts of the body. [Meditation] might also help
relax small muscles that control the blood vessels themselves; when
that happens, the resulting elasticity of blood vessel walls would
help reduce the pressure inside of them. (p. 50)
Benson and Wallace (1972) reported on 22 hypertensive patients,
whose mean blood pressure before meditation was 150/94 mmHg and
who had no prior meditation experience before being taught TM. After 4
to 63 weeks of meditation practice, their mean blood pressure was
reduced to 141/87 mmHg. Stone and DeLeo (1976) studied the difference
in blood pressure between a treatment group of 14 hypertensive patients
taught Buddhist meditation and a control group of 5 hypertensive
patients. The treatment group recorded average blood pressure reductions
of 9 mmHg systolic/8 mmHg diastolic while supine, and 15 mmHg
systolic/10 mmHg diastolic while upright. In the control group, the mean
blood pressure decrease was only 1 mmHg systolic/2mmHg diastolic
while supine, and 2 mmHg systolic/0 mm diastolic while upright.
Goleman and Schwartz (1976) exposed 30 experienced meditators
of various orientations and a control group to a stressor film, measuring
70

skin conductance, heart rate, blood pressure, self-report, and personality

scales. In comparison to the control group, the meditators heart rates and
blood pressures recovered more quickly from stressful impacts, lending
weight to the role meditation could play in preventative and rehabilitative
medicine.
As can be seen above, the effectiveness of meditation in decreasing
blood pressure has been established in many studies despite the variance
in the amount. Most likely this variance occurs due to different types of
meditative practices, levels of experience of the practitioner, kinds of
measurements, and differences in patient hypertensivity. What is also
evident is that these results are dependent on compliance with the
meditation regime (Delmonte, 1984a). Most studies (Frankle, 1976; Patel,
1976) confirm the fact that the physiological benefits of mindfulness
require continuous practice, and decline some time after the intervention
is discontinued. As discussed in the previous chapter, Buddhism
advocates life long learning and lifestyle changes rather than focusing on
specific treatments for disease or any sort of quick-fix approaches, such as
drugs, although at times they might be necessary.

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Metabolic and Respiratory Systems

Murphy and Donovan (1998) indicated in their review that in 40
studies meditation reduced oxygen consumption (in some cases up to
55%), carbon dioxide elimination (in some cases up to 50%), and
respiration rate (in some cases 1 breath per minute where the average is 12
to14). Other studies suggested that meditators could suspend their
breathing longer than control subjects with no apparent ill effects. These
studies confirmed that meditation lowered the bodys need for energy as
well as its need for oxygen to help metabolize this energy. The studies also
noted that this hibernation effect occurred only in passive rather than
active styles of meditative practice.
An extreme example comes from Vakil (1950) report in which a
middle-aged yogi was confined for more than 56 hours inside a laboratory
constructed, air tight cubicle (5 x 5 x 8 feet) lined with thousands of rusty
nails. The cubicle was then filled with 1, 400 gallons of water, in which the
yogi remained for an additional 7 hours. The subject was then removed
and found to have a normal pulse, blood pressure, and respiration rate. It
should be noted again, however, that advanced autonomic controls are
the consequences rather than the goals of Buddhist mind/body
approaches.
Muscle Tension
In recent experiments (Murphy & Donovan, 1999) involving
passive meditation, it was shown that there was a reduction in muscle
tension, just as there was in oxygen consumption. Studies suggest that in
mindfulness practice, the relaxation response lowers the need for
72

defensive armoring, while conditioned expectations of threats are

consciously recognized as irrational. Such physiological relaxation of the
muscular system contributes to the bodys lowered need for energy,
slowing of respiration, and deactivation of stress-related hormones.
Murphy and Donovan stated that as many as 15 studies showed that
meditation reduces muscle tension.

The Value of Mindfulness Meditation in Medical Populations

For almost 30 years, scientists studying the physiological effects of
various meditation practices have come to a broad consensus that passive
techniques, such as TM, Bensons relaxation and Buddhist mindfulness,
reverse the negative effects of the fight-flight response. Meditation
significantly reverses the sympathetic activation of nervous systems
including heart rate, respiration, blood pressure, metabolism and muscle
tension. This clearly establishes the effect that self-regulatory mind/body
intervention has on previously considered involuntary autonomic,
respiratory and perceptual functions. Given these conclusions I shall now
examine how mindfulness can be effective when used in a clinical
population as a treatment protocol in behavioral medicine.
Chronic Pain
Kabat-Zinn (1982) discussed some theoretical considerations and
preliminary results pertaining to an outpatient program in behavioral
medicine for chronic pain patients. Mindfulness meditation was the
primary treatment in a 10-week stress reduction program to train chronic
pain patients in self-regulation. Fifty-one patients who had not improved
73

with traditional health care participated in the program. The dominant

pain categories were neck, shoulder, lower back, and headache. Facial
pain, angina pectoris, noncoronary chest pain, and gastrointestinal (GI)
pain were also represented. Data were collected from various pain,
nonpain, and follow-up measures prior, during, and 7 months after the 10week program.
The results of the study demonstrated that the majority of patients
experienced considerable improvement in their conditions over the 10week training course in mindfulness meditation. All categories of chronic
pain were included. Most of the pain reduction and affect improvement
was maintained at follow-up. Furthermore, the data suggest that a
program based on Buddhist meditation could be successfully integrated
into a hospital setting, and that patients with chronic pain could derive
considerable benefit from such a program. Kabat-Zinn (1982) concluded
that,
beyond the reduction in pain levels and pain related behaviors, the
majority of patients evidenced attitudinal and behavioral changes
which can be attributed to the practice of mindfulness meditation:
an ability to observe mental events, including pain, with a sense of
detachment; cognitive changes which appear directly related to the
experience of detachment; and an increase awareness of oneself in
relationship to others and to the world. Deep personal insights,
greater patience, a new ability to relax in daily life situations and a
willingness to live more in the present moment were all commonly
reported, as were increased awareness of stressful situations and an
improved ability to cope successfully. (p. 46)
It appears that mindfulness practice facilitated an attentional
attitude characterized by detached observation not present in other
meditation practices. Additionally, Kabat-Zinn et al. (1985) suggest that
attentional stance appeared to cause a separation (uncoupling) of the
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physiologic/sensory dimension of pain from the cognitive/affective

reaction to it.
While Kabat-Zinns (1982) study showed the effectiveness of
mindfulness as a treatment for chronic pain, he acknowledged some
limitations to his study. These included a lack of match comparison
control groups and the unreliability of self-reported measures. Finally, the
self-discipline and competence needed to maintain adherence to the
practice of mindfulness varied from patient-to-patient. There was also the
argument that this behavioral modification offered no deep structural
change, and that the health benefits could not be maintained at follow-up
exceeding six months.
Kabat-Zinn, Lipworth, Burney, and Sellers (1987) addressed some
of these concerns in a four-year follow-up study of the MBSR program for
chronic pain. Two hundred and twenty-five chronic pain patients who
completed the 10-week stress reduction program over the past 5 years
were studied longitudinally. Measures of follow-up status were obtained
on four questionnaires, which were mailed to the study population over
the course of 4 years. The results revealed that a statistically significant
reduction in negative symptoms was maintained on three of the four
measures. The last measure tended to return to preintervention measures,
but this could have been the result of a change in the method of
administration at follow-up. Seventy-two percent of responding subjects
reported moderate to great improvement in pain status at 6 months, 1
year, and 3 years; while 62% and 60%, respectively, reached this level at 2
years and 4 years. A high proportion of respondents rated the program as
75

very important at all follow-up intervals, and attributed much of their

improvement in pain status to the intervention of mindfulness meditation.
These health benefits may have been the result of the continued
practice of mindfulness long after the program. Ninety-six percent of
responders reported compliance with the intervention at some level.
About 76% were practicing mindfulness as much as three times a week for
up 3 years after the program. In the study (Kabat-Zinn et al., 1987), it was
assumed that
training in a rigorous consciousness discipline, such as mindfulness
meditation, in a clinical setting can optimize multiple aspects of the
cognitive-behavioral learning process in chronic-pain patients and
thereby promote positive change. The meditation practice evokes a
new pattern of perceiving based on intentionally paying attention
in a moment-to-moment mode. It is thus potentially applicable to a
wide range of human activities and experiences. Mindfulness
meditation can be thought of as a generalized reference-frame shift
from partial awareness (an automatic pilot mode of functioning) to
moment-to-moment awareness with a nonjudgmental, witnessing
quality. . . . There are strong theoretical and practical reasons which
suggest that a learned and intentional use of moment-to-moment
awareness can have a profound effect on pain perception, the
experience of suffering, and on stress reactivity. (p. 171)
The follow-up findings supported the fact that mindfulness meditation in
the context of stress reduction produced long-term improvement and high
satisfaction in an ambulatory pain population. Similar findings regarding
the use of mindfulness to increase pain tolerance were reported by Hayes,
Bissett, et al. (1999).
Anxiety
Murphy and Donovans (1999) review of the literature identified as
many as 100 studies focusing on the relationship between meditation and
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anxiety. There was a general consensus among these reports that

meditation decreased acute and chronic forms of anxiety. Loizzo (2000)
was convinced that for anxiety, meditation was now the intervention of
choice. Noteworthy research includes DeBerry (1982) who studied 36
elderly women (mean age 71), 83% of whom were widows, in a 20-week
study designed to evaluate the effects of mindfulness on symptoms of
anxiety and depression. Subjects were selected because of chronic
complaints of anxiety, nervousness, tension, fatigue, insomnia, sadness,
and somatic issues. Twelve subjects were randomly assigned to each of
three groups: (a) an experimental meditation group; (b) an experimental
meditation group, with a 10-week follow-up practice Involving
meditation tapes; and, (c) a pseudorelaxation control group. The
Spielberger Self-Evaluation Questionnaire and the Zung Self-Rating
Depression Scale were administered before treatment, at the end of the 10week training period, and at the end of the follow-up period for group
two.
In comparison to the control group, the two treatment groups both
manifested a significant pretreatment to posttreatment decrease in both
state and trait anxiety. When the two treatment groups were compared,
the group with a follow-up practice continued to show a decrease in state
anxiety; while the treatment group without follow-up exhibited a return
to baseline levels. Similar pretreatment to posttreatment decreases in
depression were found for both treatment groups when compared to the
control, and the ongoing practice group maintained these significant
decreases when compared to the nonpractice group.
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Taking into consideration the variance in meditative experiences,

Davidson, Goleman, and Schwartz (1976a) studied intentional absorption
and anxiety in 58 subjects assigned to four groups: (a) controls who were
interested in learning but who did not practice meditation; (b) beginners
who had practiced meditation for 1 month or less; (c) short-term
meditators who had practiced for 1 to 24 months; and, (d) meditators who
practiced for over 2 years. All subjects were given the Short Personal
Experiences Questionnaire, the Tellegen Absorption Scale, and the
Speilberger State-Trait Anxiety Inventory. The results indicated a reliable
increase in meditative absorption, in conjunction with a decrease in trait
anxiety proportionate to the length of time meditating.
Vahai, Doongaji, and Jeste (1973) studied 95 outpatients diagnosed
as psychoneurotic. All failed to show improvements as a result of
traditional treatments. Half were randomly selected for an experimental
group that was instructed in meditation and yoga exercises, while the
other half, acting as a control, were given pseudotreatments consisting of
breathing and stretching exercises. The treatment involved one hour of
practice per day for 6 weeks. Both groups received the same support,
reassurance, and placebo tablets. Following treatment, the experimental
group shows significant mean decreases in anxiety, measured on the
Taylor Manifest Anxiety Scale. The control group exhibited no significant
change on this scale. Overall, 74% of the experimental group was judged
to be clinically improved as a result of meditation and yoga.
A pilot study on the effectiveness of MBSR as a treatment for
anxiety disorder was undertaken by Kabat-Zinn et al. (1992) Twenty-two
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study participants were screened and met criteria for generalized anxiety
disorder, or panic disorder, with or without agoraphobia. The subjects
then began an 8-week stress reduction program based on self-regulation
through mindfulness. The results of the program were consistent with
previous studies. There was a high completion rate of about 92%. After
the intervention, 20 of the 22 patients who finished showed a marked
improvement in coping with both anxiety and depression. This
improvement was maintained at three month follow-up. According to the
study,
Patients who are able to identify anxious thoughts as thoughts,
rather than as reality, report that this alone helps to reduce their
anxiety and increase their ability to encounter anxiety-producing
situations more effectively. The insight that one is not ones
thoughts means that one has a potential range of responses to a
given thought if one is able to identify it as such. This increase in
options is associated with a feeling of control. It might be
hypothesized that this a feature of a cognitive pathway explaining
the clinical observations of this study. (p. 942)
This study demonstrated statistically and clinically significant
reductions in the symptoms of the participants. It underscored the fact
that a significant component of mindfulness intervention is its emphasis
on detached observation, which enables practitioners to see and respond
more clearly to stressful situations rather than automatically reacting to
them. It also indicated the need for further investigations on its long-term
effects.
J. Miller, Fletcher, and Kabat-Zinn (1995) discussed their findings in
a 3 year follow-up to the mindfulness intervention in the treatment of
anxiety disorder. Of the original 22 patients who participated in the 1992
study, 18 were contacted to determine the long-term effects. This follow79

up report focused on the maintenance of the originally observed

improvements on all the outcome measures used 3 years previously. It
also examined a much larger majority of participants in the stress
reduction program who were not involved in the initial study. These
findings provided strong evidence that an intensive, MBSR intervention
was a clinically effective treatment for anxiety disorder. The study also
showed a significant decrease in depression scores in anxious patients,
suggesting that mind/body interventions could be equally effective in
reducing symptoms of other mental illnesses. This finding would later
serve as a rational in the development of Mindfulness-Based Cognitive
Therapy for Depression (Segal et al., 2002).
The J. Miller et al. (1995) study highlighted some noteworthy
components of the intervention, one such feature being its orientation
towards the general category of stress rather than toward a specific
diagnostic entity. In this way, mindfulness was seen as not focusing on the
treatment of anxiety, but rather on dealing more effectively with stress,
pain, and chronic illness through self observation and the self regulation
of intrapsychic and external behaviors (p. 196). The nonspecific
orientation of mindfulness differed paradigmatically from conventional
biomedical, psychiatric, and even behavioral medicine models, which
advocated specific treatments for specific disorders. Instead, mindfulness
was viewed as being focused on the nonspecific component of stress,
which underlay and/or exacerbated many medical symptoms (Rabkin,
1982). In addition, as J. Miller et al. stated,
the intervention is oriented toward what is right with people
rather than what is wrong with them and aims to nurture and
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strengthen innate capacities for relaxation, awareness, insight and

behavioral change. The emphasis on this program is to encourage
each individual to explore his or her own inner resources for
growth and learning and healing, and to systematically cultivate
mindfulness in all areas of daily life, including those times in which
they find themselves confronting distressing symptoms and
problems. (p. 197)
Psoriasis
These observations reiterate the potential of meditation to
transform an individuals way of seeing and dealing with pain rather than
attempting to change the pain itself. As this strategy is not disorderspecific, it may be applied as a treatment for, or as an adjunct to, a variety
of clinical and medical issues. An example of this versatility comes from a
preliminary report by Bernhard, Kristeller, and Kabat-Zinn (1988) which
investigated mindfulness and visualization meditation as adjunctive
therapies to phototherapy (UVB) or photochemotherapy (PUVA) in the
treatment of psoriasis. This study involved 12 patients who underwent
traditional phototherapy and photochemotherapy. The patients were
randomized into two groups, 8 in an experimental group and 4 in a
control group. The experimental group practiced guided meditations
received on an audiotape while undergoing ultraviolet treatment. The
ultraviolet treatment session was an ideal time to practice meditation
because the patient was confined in a room for over 45 minutes during a
highly stressful procedure. Results were collected at a turning point, when
improvement was first detected; at a halfway point, when psoriasis was
reduced by half; and at a clearing point when less than 5% of the psoriasis
remained. Comparisons of the two groups showed that the turning point
and the halfway point occurred significantly earlier for the experimental
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group. Furthermore, 7 of the 8 patients in the experimental group

achieved a 95% reduction of psoriasis in a mean of 19 sessions, whereas
only 1 of the 4 patients in the conventional group achieved clearing in less
than 40 sessions.
While these results were preliminary due to the small sample size,
they do merit further investigation into the potential health benefit of
mindfulness as an adjunctive treatment for psoriasis. While mindfulness
did not treat the psoriasis directly, it most likely had an effect on the
patients relationship to the disease and its treatment, significantly
increasing the recovery rate.
Kabat-Zinn et al. (1998) followed up their initial mindfulness-based
treatment for psoriasis study with better methodological controls and a
larger sample size. 37 patients with psoriasis about to undergo UVB or
PUVA were randomly assigned to one of two conditions: a mindfulness
meditation-based stress reduction intervention guided by audiotaped
instructions during light treatments, or a control condition consisting of
the light treatments alone with no taped instructions. Psoriasis status was
assessed in three ways: direct inspection by unblinded clinic nurses, direct
inspection by physicians blinded to the patients study condition (tape or
no tape), and blinded physician evaluation of photographs of psoriasis
lesions. In a similar way to the previous experiment, four sequential
indicators of skin status were monitored: a first response point, a turning
point, a halfway point, and a clearing point.
According to the results, for both UVB and PUVA treatments, Coxproportional hazards regression analysis showed that subjects in the tape
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groups reached the halfway point (p = .013) and the clearing point (p =
.033) significantly more rapidly than those in the no-tape group. Overall
the meditators cleared at approximately four times the rate of those
subjects receiving light treatment without the guided meditation tape
intervention. This was consistent with rates recorded during the 1988
study. The authors concluded that a brief mindfulness meditation-based
stress-reduction intervention delivered by audiotape during ultraviolet
light therapy could increase the rate of resolution of psoriatic lesions in
patients with psoriasis (Kabat-Zinn et al., 1998).
Overall there is growing support for mind-body therapies in the
treatment of various medical illnesses. A recent meta-analysis conducted
by Astin, Shapiro, Eisenberg, & Forys, (2003) drew the following
conclusions for the effectiveness of mind-body approaches including
mindfulness meditation:
We believe that the cumulative clinical evidence reviewed here
lends strong support to the notion that medicine should indeed
adopt a biopsychosocial rather than exclusively biologic-genetic
model of health. . . . Based on the positive findings of metaanalyses and randomized controlled trials, there is strong evidence
to support the incorporation of an array of mind-body approaches
in the treatment of chronic lower back pain, coronary artery
disease, headache, and insomnia; in preparation for surgical
procedures; and in the management of a treatment and diseaserelated symptoms of cancer, arthritis, and urinary incontinence.
Although we have noted several areas that future research should
address, given the relatively infrequent and minimal side effects
associated with such treatments and the emerging evidence that
these approaches also result in significant cost savings, we believe
that the integration of psychsocial-mind-body approaches,
particularly in the clinical areas highlighted above, should be
considered a priority for medicine. (p. 144)

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Cancer
Several preliminary clinical trails reported improvements on
various measures when mindfulness meditation was applied to a serious
medical condition such as cancer (Carlson, Ursuliak, Goodey, Angen, &
Speca, 2001; Carlson, Speca, Patel, & Goodey, 2003, 2004; Speca, Carlson,
Goodey, & Angen, 2000), HIV (F.P. Robinson, Mathews, & Witek-Janusek,
2003), and fibromyalgia (Austin et al., 2003; Kaplan, Goldenberg, &
Galvin-Nadeau, 1993; B. Singh, Berman, Hadhazy, & Creamer, 1998).
Speca et al. (2000) conducted an initial randomized, wait-list controlled,
clinical trial to determine effects of MBSR on a heterogeneous patient
population with various types and stages of cancer. Patients completed
the Profile of Mood States (POMS) and the Symptoms of Stress Inventory
(SOSI) both before and after the intervention. Ninety patients (mean age,
51 years) completed the study. Patients' mean preintervention scores on
dependent measures were equivalent between groups. After the
intervention, patients in the treatment group had significantly lower
scores on Total Mood Disturbance and subscales of Depression, Anxiety,
Anger, and Confusion, and increased Vigor than control subjects. The
treatment group also had fewer overall Symptoms of Stress; fewer
Cardiopulmonary and Gastrointestinal symptoms; less Emotional
Irritability, Depression, and Cognitive Disorganization; and fewer
Habitual Patterns of stress. Overall reduction in Total Mood Disturbance
was 65%, with a 31% reduction in Symptoms of Stress. The study was
limited by the absence of a posttreatment follow-up.

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Carlson et al. (2001) examined the use of mindfulness in a cancer

trial similar to Speca et al. (2000), this time including a 6-month follow up.
All patients completed the POMS and the SOSI, before and after the
intervention and six months later. A total of 89 patients (mean age 51)
provided preintervention data. 80 patients provided postintervention
data, and 54 completed the 6-month follow-up. The participant profile
was consistent with the earlier study, heterogeneous with respect to type
and stage of cancer. In general, patients' scores decreased significantly
from before to after the intervention on the POMS and SOSI total,
indicating less mood disturbance and fewer symptoms of stress, and these
improvements were maintained at the 6-month follow-up. The diversity
of the sample strengthened the generalizability of the findings.
Limitations of the study included failure to use control group and
unpredictability of the natural course of the illness.
Of particular interest were the improvements on the depression,
anger, and anxiety subscales, since these were the most frequently
reported psychological symptoms identified by cancer patients. In their
review of the literature prior to the study, Carlson et al. (2001) indicated
that up to 53% of cancer patients were diagnosed with major depressive
disorder and up to 30% with adjustment disorder. While the authors
expected to see physiological changes as a result of meditation such as
decreased sympathetic nervous system arousal, the greatest changes
occurred on the cognitive subscales leading to enhanced psychological
well-being (p. 119). Here again, the strength of mindful meditation is

85

not in treating the cancer per se, but in its ability to help patients improve
their subjective experience in relation to it.
Carlson et al. (2001) also noted, that more advanced stages of
cancer were associated with less mood disturbance, attributing this to
patients having to confront their mortality, which earlier stage cancer
patients could continue to delay and deny. The use of mindfulness
meditation to deal with existential issues, and patients enhanced efficacy
to face the future fear of death with peaceful equanimity were major
benefits reported by patients in their program feedback. As one
testimonial from the study suggests,
In times of pain, when the future is too terrifying to contemplate
and the past too painful to remember, I have learned to pay
attention to right now. The precise moment I was in was always
the only safe place for me. Each moment taken alone, was always
bearable. In the exact now, we are, always, all right. . . . [Another
patient reported] The meditation helped me focus on the present
and reduce my fear of the future, which primarily that I would die.
I have learned there are ways to live within stressful situations,
events and conditions and find an island of peacefulness. (p. 120)
Carlson et al. (2003) showed decreases in stress and mood
disturbance, and improvements on a quality of life measure in a mixed
gender, early-stage breast and prostrate cancer patient population
following an 8-week MBSR intervention with pre/post design. The study
was unique in that it examined immune functioning parameters.
Although there were no significant changes in the overall number of
lymphocytes or cell subsets, production of specific cells that inhibited
cancer cell growth increased, whereas those associated with stress level
and depression decreased. These results were consistent with a shift in
immune profile from one associated with depressive symptoms to a more
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normal profile. The authors suggested that mindfulness might be a

promising adjunct to surgery and chemotherapy, but recommend larger
full-scale controlled trails.
Cohen, Warneke, Fouladi, Rodriguez, & Chaoul-Reich, (2004)
waitlist controlled clinical trail examined the effectiveness of a Tibetanstyle mindfulness program for patients with lymphoma. Contrary to
studies by Carlson et al. (2001, 2003, 2004) and Speca et al. (2000), the
program showed no statistically significant decreases in levels of
depression and anxiety. However, the experimental group recorded
significantly lower sleep disturbance scores during follow-up compared
with patients in the wait-list control group (5.8 vs. 8.1; p < 0.004). This
included better subjective sleep quality (p< 0.02), faster sleep latency (p <
0.01), longer sleep duration (p< 0.03), and less use of sleep medications (p<
0.02). The authors proposed that patients undergoing or recently
completed (within 12 months) conventional treatment could not only meet
the challenges of intensive meditation program, but could also learn
behavioral strategies aimed at coping with the difficulties of invasive
treatment, leading to improved sleep-related outcomes.

Summary
This chapter has highlighted some of the ways in which Buddhist
meditation can be therapeutically beneficial as a primary treatment, or as
an adjunct treatment, in behavioral medicine. The current literature
indicates that mindfulness meditation enables practitioners to successfully
cope with chronic pain and anxiety, as well as other stress-related
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disorders, such as psoriasis. Furthermore, improved quality of life can be

achieved for those currently involved in, or recently completing,
conventional treatment for more serious medical illness such as cancer,
HIV and fibromyalgia. This success of mindfulness meditation can be
attributed both to the physiological changes that counteract stress as well
as the perceptual retraining or cognitive-affective uncoupling aspect that
reduces emotional disturbances such as depression and anxiety. The
practice of mindfulness meditation involves an internal change in
patients response to problems, and offers an alternative strategy of
dealing with suffering. In its most dramatic application, mindfulness
meditation prepares patients to meet the challenges posed by existential
issues due to terminal illness. This behavioral approach harnesses the
mind/body connection, which contrasts with most conventional medical
approaches that aim to reduce symptoms by eliminating only the
superficial causes of illness through highly invasive surgeries, treatments
and medications. We now move to the neurological effects of mindfulness
meditation.

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CHAPTER 5: MINDFULNESS MEDITATION IN COGNITIVE

NEUROSCIENCE

Introduction
The present study now proceeds to determine the effects of meditation on
the brain by reviewing studies in the field of cognitive neuroscience.
Electroencephalographic (EEG) studies of meditative states have been
conducted for almost 50 years, but have yet to reveal a consensus
understanding about the underlying neurophysiologic changes that occur
as a result of such a practice. Sensory evoked potential and cognitive
event-related potential assessments of meditative practice have also
provided inconsistent results. Some reliable meditation-related EEG
frequency effects for alpha and theta activity have been observed.
Positron emission tomography (PET) and functional magnetic imaging
(fMRI) studies are beginning to increase in the literature, providing more
refined neuroelectric data. These studies suggest possible neural loci for
meditation effects; although how and where such practice may alter the
central nervous system have not yet been clearly identified.
Thus far, broad and encompassing statements about the neurophysiology
of meditation are misleading and premature, because it appears that
different meditative techniques produce distinct brain effects (Dunn et al.,
1999; Lazar et al., 2003; Lehmann et al., 2001; Lou et al., 1999, 2004; Lutz et
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al., 2004). Some progress has been made to identify structure-function

central nervous system relationships of meditative states and traits (Travis
& Wallace, 1999), with changes in arousal and attentional state involved in
meditation also related to drowsiness, sleep, and unconsciousness
(Austin, 1999; Vaitl et al., 2005).
In neuroscience, the research emphasis shifts from understanding
interpersonal and subjective phenomena to the neurochemistry and
physiological microprocesses that underlie them, both in illness and in
health. This shift can be applied to the emerging field of meditation
research because it provides a language relevant to Western science, a
language by which clinicians and researchers can study the benefits of
ancient self-healing disciplines.
For centuries, Buddhist psychology (Abhidharma) has meticulously
accounted for a variety of mental experiences that occur during
meditation from the inside out. Now, with the use of neuroscientific
techniques, it is possible to account for the same processes from the
outside in. The power of noninvasive technologies has made it possible to
investigate the nature of cognition and emotion in the brain, and to
explore the interfaces between mind, brain, and body. Such an exploration
has the potential to explain the implications of particular forms of
meditative practices, including mindfulness, for modulating and
regulating biological pathways. In this way, clinicians can learn how to
enhance homeostatic processes and extend the reach of mind and body in
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ways that promote rehabilitation and healing as well as greater overall

health and well-being.
As reviewed in the last chapter, numerous studies have documented
peripheral autonomic changes associated with meditation practice, such
as heart rate, respiration, and muscle tension; but, our inability to directly
observe brain activity has limited understanding. In the last few decades
however, efforts have been underway to define the neurological effects of
meditation, including distinctions in brain effects produced by various
forms of practice as well as distinctions between altered and normal states
of consciousness (Davidson, 1976, 1994, 2000; Tart, 1975). Recent studies
(Davidson et al., 2003; Lutz et al., 2004) showed that, when cultivated over
time, meditation resulted in stable brain patterns and changes previously
undocumented, suggesting a potential for the systematic development of
positive neuroplastic modifications through such a practice. These
investigations offer opportunities for understanding the basic unifying
mechanisms that underlie awareness as well as the capacity for effective
adaptation to stress (Loizzo, 2000; Rabkin, 1982).
This chapter reviews studies that focused on the neurological effects of
mindfulness practice. In the literature regarding this subject, the primary
question that emerges is whether or not Buddhist meditation has its own
unique set of neurological characteristics, distinguishing it from rest,
sleep, and higher states of consciousness produced by different meditation
practices. Additionally, attention is paid to the state and trait effects of
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meditation in general and mindfulness in particular. A second area of

inquiry pertains to shifts in hemispheric dominance that result from
meditation. Third, this chapter investigates how meditation can increase
positive affect, reverse the long-term physiological damage caused by
cumulative stress, and activate the brains natural neural plasticity.
Neurological Correlates of Mindfulness Meditation
EEG and Alpha Activity
The EEG signal generated by alpha (8 to12 Hz) activity was first
described by Berger (1929) with the demonstration that closing the eyes
decreased sensory input and increased alpha power over the occipital
scalp (Berger, 1929). EEG studies have used these methods to describe the
neurophysiologic changes that occur in meditation. Although the
neuroelectric correlates of meditative altered consciousness states are not
yet firmly established, some preliminary data suggests meditation
increases in theta and alpha band power and decreases in overall
frequency (Andresen, 2000; Davidson, 1976; Delmonte, 1984b; Fenwick,
1987; Schuman, 1980; D. H. Shapiro, 1980; D. H. Shapiro & Walsh, 1984;
West, 1979, 1980a; Woolfolk, 1975).
A highly controversial study by Holmes et al., (1983) investigated
the arousal-reducing effects of meditation in comparison to simple rest.
Using a strict methodology involving experimental control, the authors
found that both meditation and rest resulted in decreased arousal; but,
contrary to their initial expectation, meditation did not produce greater
reductions in arousal than rest. According to Holmes et al. (1983), this

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finding brought into question the potential relevance of meditation

altogether.
Based on EEG monitoring there is an extensive body of
neurological evidence cited by Delmonte (1984b) and West (1980a) that
demonstrated similar brain patterns during rest and meditation. Murphy
and Donovans (1998) review included as many as 30 studies, reporting
that meditation and rest involved a similar increase in alpha activity.
These slow, high amplitude brain waves, extending to anterior channels
and ranging in frequency from 8 to 13 cycles per second, appeared when
the subject began to feel drowsy, around stage one and two before the
onset of sleep. The fact that meditation and rest caused drowsiness and
resulted in similar neurological effects supported Holmes et al. (1983)
findings that they decreased arousal in much the same way.
The results of the study by Holmes et al. (1983) were received with
much criticism, particularly by those researchers who, according to their
own investigations, endorsed the use of meditation. Several years later
Holmes (1987) reevaluated his findings in light of the concerns raised by
his colleagues (Benson & Friedman, 1985; Shapiro, 1985; Suler, 1985; West,
1985), and published them as a chapter in the Psychology of Meditation
(West, 1987). Among the most significant and convincing criticisms were
those made by Suler (1985) who cautioned Holmes not to throw the
psychological effects out with the physiological effects.
Furthermore, Suler (1985) pointed out that if it was correct that
meditation did not affect somatic activity [more than rest], let us be
careful to avoid conclusions that its effectiveness in other realms must
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therefore be restricted (p. 99). Holmes (1987) responded to this by

conceding that his evidence was limited to the effects of physiological
arousal. He avoided further explanation by stating that, those other
effects are beyond the scope of this review (p. 99). In his concluding
remarks, Holmes (1987) discussed his latest line of research involving the
effects of physical fitness, and reiterated his skepticism of meditation: I
can strongly recommend to persons who are interested in reducing
arousal to spend their time exercising rather than meditating or resting
(p. 102).
In line with Sulers (1985) counter argument, it is important to
demonstrate how Holmes et al. (1983) original conclusions were both
misleading and inaccurate. First of all, Holmess study recorded brain
activity during meditation and rest for only short periods of time. At
certain intervals, in terms of decreased arousal, meditation appeared to be
similar to rest; but if recorded over extended periods of time, brain waves
fluctuated as the meditation practitioner regulated his awareness
(Davidson et al., 2003; Lazar et al., 2000). This contrasts with
measurements of rest in which reduced arousal is either maintained or
further decreased as deeper stages of sleep are entered. Holmess
conclusions were restricted to a single meditative moment that appeared
similar to rest; and was, therefore, misleading in terms of the entire
process.
Holmes (1987) also did not study the differences in various
meditative techniques, and he made a common error when he asserted
generalizations about all types of practice. As was shown in Chapter 3,
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Buddhist meditation training uses concentration (shamata or samadhi)

provisionally as a foundation practice to stabilize and quiet the mind. This
effect of decreased arousal is a prerequisite mental state conducive to the
integration of other types of meditative disciplines (Bucknell & Kang,
1997). As B.A. Wallace (1998) pointed out,
Indo-Tibetan Buddhism regards the ordinary, untrained mind as
dysfunctional insofar as it is dominated by alternating states of
laxity, lethargy, and drowsiness on the one hand and excitation and
attentional scattering on the other. The cultivation of quiescence
[concentration] is designed to counteract these hindrances and
cultivate the qualities of attentional stability and clarity, which are
then applied to training in insight. (p. 12)
The difference between rest and meditation is that the meditator
consciously regulates and manipulates his relaxation, while the resting
subject is often overcome by sleep (Davidson et al., 2003; Lou et al., 1999).
It is within the therapeutic space of restful alertness that the practitioner is
able to employ mindfulness meditation (satipatana) and analytic investigation
(vipassana) of sensations, emotions, thoughts, and consciousness.
As in free association, it is through relaxed observation that practitioners
work with their own addictions, compulsions, and unrealistic viewsall
of which can lead to profound and sustained transformation and trait
effects. Holmess study suggests that there is no neurological difference
between meditation and rest, but this is misleading because mindfulness
meditators show continuous shifts in arousal over extended periods of
time during which they consciously regulate a manipulate states of
relaxed awareness (Davidson et al., 2003; Lazar et al., 2000; Lou et al.,
1999). Furthermore, the moments when meditation does appear similar to
rest has the purpose in Buddhist training for the integration of advanced
95

practices of meditative learning. This integration contrasts with most other

meditative disciplines that use relaxation exclusively. While it is true that
alpha power increases during meditation because of relaxation (Morse,
Martin, Furst, & Dubin, 1977), it is necessary to understand the
mechanisms of Buddhist meditation in order to make useful sense of the
neurological data, a concept that Holmes et al. (1983) failed to perceive.

Alpha Blocking Versus Alpha Habituation

There is strong neurological evidence that distinguishes
concentration from mindfulness types of meditation. Das and Gastaut
(1955), Bagchi and Wenger (1957, 1958), Anand and Chhina (1961) and
Kasamatsu et al. (1957) were among the first to use portable EEG
machines on advanced meditators of different meditation traditions
practicing in their natural context. Das and Gastaut (1955) studied 7
Indian adepts and found that concentration led to decreases in alpha
amplitude and increases in alpha frequency, suggesting that this practice
was a consciousness altering procedure. They also detected generalized
bursts of spindles of fast activity during culminating absorptive peak
experiences (samadhi).
Bagchi and Wegner (1958) similarly studied Indian yogis
intensively practicing concentration in caves in the Himalayas. They
recorded EEG measures during the meditation session while attempting
to distract the yogis with crashing cymbals and flashing lights, as well as
by putting their feet in cold water. They reported that in most cases the
alpha rhythm was not blocked by sensory input, indicating that during
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advanced stages of concentration the adepts were completely unaffected

by external stimuli. Together with fast rhythms during samadhi, sensory
withdrawal is the distinguishing neurological features of most
concentrative meditation practices.
These findings have continued to be supported in more recent
studies. Aftanas and Golocheikine (2005) examined the neurological
effects of distressing stimulus on advanced subjects practicing Sahaja yoga
compared with a control group. Their data revealed that meditators have
a statistically significant increase in their ability to moderate the intensity
of emotional arousal.
In contrast, the findings of Kasamatsu et al. (1957) described the
features of zazen meditation, which is analogous to the mindfulness type
of practice used exclusively in Buddhist training. Using 48 Japanese
monks as subjects, the researchers recorded fast alpha activity with the
frequency of 11 to12 Hz at the commencement of the meditative session.
They noted that alpha activity with the eyes open was similar to activity
typically seen with the eyes closed, suggesting that zazen is a less aroused
state than normal waking consciousness. This finding was reinforced by
increased alpha amplitude and decreased alpha frequency, mainly in the
frontal and central regions of the brain. During the later course of the
session, the practitioners showed greater decreases in alpha activity
suggesting that zazen was similar to sleepa point these and other
authors have subsequently refuted.
Using click stimulation, the researchers found a block in alpha
activity, which returned several moments later indicated the presence of
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awareness and precluded sleep. Similar alpha blocking effects were found
in a group of Zen monks examined by Lo, Huang, and Chang (2003).
Increases in theta and alpha coherence above baseline resting wakefulness
was commonly found during meditation, further differentiating
meditation from drowsiness and early sleep stages (Aftanas &
Golocheikine, 2003; Travis, 1991; Travis, Tecce, Arenander, & Wallace,
2002; Travis & Wallace, 1999). Increases in overall cerebral blood flow
during meditation had been observed, whereas decreases were
characteristic of sleep (Jevning, Fernando, & Wilson, 1989). This outcome
may be related to findings of increased melatonin levels in meditators at
baseline, and increased levels in meditators during sleep on nights after
meditating (Harinath et al., 2004). These results combined to support
subjective reports that meditation and sleep were not equivalent states
(Aftanas & Golocheikine, 2001; Delmonte, 1984b; Ikemi, 1988).
Another significant finding from the Kasamatsu et al. (1957) study
was that the meditators showed no habituation to the click response. The
alpha activity was blocked for the same length of time following repeated
auditory stimulus, without habituation. In contrast to the concentrative
practices that did not block alpha waves and habituate to external
distractions, mindfulness blocked alpha activity indicating an acute
receptivity towards sensory input. Moreover, the absence of habituation
suggested a moment-to-moment alertness rather than sensory isolation.
This characterized one of the main neurological differences between the
narrow and exclusive foci of concentration, and the receptive and
inclusive attentional focus of mindfulness.
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The authors described zazen as involving both attentional stances

simultaneously. First concentration creates a calm and undistracted state
of consciousness; then mindfulness is introduced allowing receptivity to
centripetal sensory inflow. Fenwick (1987) review of the original
Kasamatsu and Hirai (1966) quoted them as saying,
the Zen masters reported to us that they had more clearly perceived
each [clicking] stimulus than in their ordinary waking state. In this
state of mind one cannot be affected by either external or internal
stimulus. Nevertheless he is able to respond to it. (p. 107)
It was also noted that the level of attentional capacity during deep
relaxation was proportionate to the meditative maturity of the
practitioner, a phenomenon known as a dose response, referring to a
process by which higher levels and longer durations of meditative activity
produce greater results and benefits. Findings delineated in the
Kasamatsu et al. (1957) study were later corroborated by Lutz et al., (2004).
Both studies were significant because they demonstrated that
concentration and mindfulness were different skills that could be
developed just as muscle tone could be sculpted by logging hours in a
gym.
Concentration is characterized by decreased arousal and sensory
withdrawal. If practiced exclusively, it can culminate in increased arousal
and ecstatic states (akin to bliss and orgasm) known in the Hindu yoga
and Buddhist meditative traditions as Samadhi (Bagchi & Wenger, 1957;
Das & Gastaut, 1955). This practice is also common to many nonBuddhist
contemplative traditions such as Hinduism Bhakti, Jewish Kabbalah,
Christian Hesychasm, and Sufism among others (Goleman, 1988).
Depending on the depth and strength of concentration, alpha activity will
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fail to block, an indication that the cortex is in sensory isolation from the
environment. In contrast, mindfulness meditation practice begins
similarly with decreased arousal, but then results in a different set of
neurological effects.
In the case of zazen, the presence of theta waves indicates deep
relaxation, while the blocking of alpha and theta waves represents an alert
attentiveness. The latter is further distinguished by a lack of habituation to
stimulus, thus indicating that the central nervous system reacts anew to
each successive moment. This demonstrates that the cortex is receptive to
new environmental input, even to a greater degree than in normal waking
consciousness. Delmonte (1984a) speculated that yogic meditators, using
narrow, focused concentration, failed to block alpha waves and habituate
to external input. Zen and other Buddhist practitioners, using a more
open mindfulness technique, blocked alpha waves and failed to habituate
to clicking stimulation. Loizzo (2000) posited that the temporary state of
relaxed alertness produced by mindfulness might become an enduring
trait by rewiring brain networks through repeated practice. Preliminary
longitudinal studies to evaluate enduring trait effects of Buddhist practice
are under way, including the Shamata Project led by Dr. B. A. Wallace,
director of the Santa Barbara Institute of Consciousness Studies and the
Cultivating Emotional Balance Project led by Dr. Margaret Kemeny and
Dr. Paul Ekman of the University of California at San Francisco.
EEG and Theta Activity
Various researchers have suggested that increased theta (4 to 8 Hz)
rather than increases in alpha power during meditation might be a specific
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state effect of meditative practice (Aftanas & Golocheikine, 2001, 2002;

Anand and Chhina, 1961; Fenwick et al., 1977; Hirai, 1960; Jacobs & Lubar,
1989; Travis et al., 2002; Wallace et al., 1971). Some studies of
concentration meditative practice found increases in theta to be associated
with dose-response and proficiency in meditative skill (Aftanas &
Golocheikine, 2001). Similarly an early study of mindfulness indicated
theta increase to be characteristic of only the more advanced practitioners
(Kasamatsu & Hirai, 1966). Theta power increases for meditative practice
have been widely reported (Aftanas & Golocheikine, 2001; Kasamatsu &
Hirai, 1966; Kasamatsu et al., 1957; Lehmann et al., 2001; Lou et al., 1999;
Wallace, 1970; West, 1980). Increased frontal midline theta power during
meditation also was observed (Aftanas & Golocheikine, 2002), although a
similar activation occurred in nonmeditation-related studies of sustained
attention (Ishii et al., 1999).
Attempting to relate this frontal midline theta to the differences
between meditation techniques, Pan, Zhang, and Xia (1994) examined two
groups of Qi-gong practitioners: those who used a concentrative style and
those who employed a mindfulness approach. Even though the level of
expertise in the two groups was equal, the concentrative Qi-Gong
technique produced frontal midline theta activity in practitioners, while
the mindfulness form did not. Although mindfulness-based practices
have been assessed with EEG less often than concentrative practices, a
comparative study by Dunn et al. (1999) found that mindfulness
meditation produced greater frontal theta than concentrative meditation.

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This outcome contradicted previous findings that indicated an association

between frontal theta and concentrative meditation.
Pan et al. (1994) also revealed that novice meditators produced
global theta that was shown to be higher during resting relaxation than
either of the two meditative conditions, thereby implicating drowsiness as
the source of the theta activity in this study. In their study, Ishii et al.
(1999) found that frontal midline theta activity was generated by anterior
cingulate cortex, medial prefrontal cortex, and/or dorsolateral prefrontal
cortex. This activity was correlated by Gevins, Smith, McEvoy, and Yu
(1997) with attention-demanding tasks and higher levels of theta activity
typically correlated with lower state and trait anxiety scores (Inanaga,
1998). Therefore, increases in frontal theta for both state and trait effects
in meditation was associated with decreases in anxiety level resulting
from practice (Shapiro, 1980; West, 1987). This finding might be
associated with common subjective descriptions, such as peace or
blissfulness, and low thought content correlated with theta burst
occurrences during concentrative meditation and initial moments of basic
mindfulness (Aftanas & Golocheikine, 2001; Lou et al., 1999).

Brain Laterality and Hemispheric Dominance

The present section addresses the following question: In what way
does meditation affect the hemispheres of the brain, and can this be used
for therapeutic ends? Recent research in neuroscience (Austin, 1999; Bear,
1986; Kessin, 1986; Loizzo, 2000) have determined the different functions
of the right and left hemispheres of the cerebral cortex. Strong evidence
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indicated that the left hemisphere of a right-handed individual was

largely responsible for verbal communication, logical reasoning, learning,
analysis, and positive emotions. The right hemisphere was associated
with intuition, visual perception, creativity, preverbal experience, negative
affect, and the unconscious.
There are several divergent perspectives in the literature. Some
researchers held the view that meditation directly activated right
hemisphere function (Davidson, 1976; Ornstein, 1971, 1972; Schwartz,
1974; West, 1987). Others asserted that meditation decreased left
hemisphere activity leading to the appearance of right hemisphere
dominance (Abdullah & Schucman, 1976; Ehrlichman & Wiener, 1980;
Meissner & Pirot, 1983; Prince, 1978). Still others (Glueck & Strobel, 1975;
Lutz et al., 2004; Westcott, 1974) pointed out that meditation increased
alpha amplitude in the left hemisphere, which later spread to the right.
The variation in findings reiterated the need for further
experimentation and research as well as a more coherent classification of
effects, according to the type of meditation practice. While there was less
agreement regarding the precise process and mechanisms of hemispheric
activation, there was general agreement that concentration types of
meditation eventually activated the right hemisphere (Aftanas &
Golocheikine, 2005).
Even though the right hemisphere might be in ascendancy only
during initial stages of meditation, EEG amplitude data suggested that
meditation could have long-term effects on specific abilities controlled by
the right hemisphere. Bennett and Trinder (1977) found that as a group,
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meditators exhibited greater asymmetrical differences between visual and

verbal tasks. Similarly, Earle (1977) found that while an arithmetic
condition was significantly left lateralized from a baseline condition for a
trained group of meditators, this was not true for an untrained group of
controls. Greater EEG asymmetry differences between verbal and visual
tasks were associated with special orientation and superior ability (Fiore,
1978). Thus, in agreement with Davidsons (1976) findings, these studies
of showed that meditation might lead to greater right hemisphere-specific
abilities.
More recently, Loizzo (2000) pointed out that neurological effects
were dependent on the type of meditation practice being studied. While
concentration activated right-hemispheric dominance, Loizzo (2000)
maintained that in insight meditation (full mindfulness) both sides of the
brain were activated simultaneously and brought into an integrated
harmony. Rather than working in a dualistic manner with each
hemisphere working unilaterally, mindfulness accessed functions
associated with each hemisphere. This seems plausible given the relaxed
and alert state that mindfulness is designed to cultivate in order to
introduce sustained analytic investigation (left hemisphere activity) of
negative affect and habitual unconscious impulses (associated with the
right hemisphere).
Loizzo (2000) proposed that mindfulness meditation might effect a
shift from left hemispheric unilateral dominance to bilateral activation.
This would enable left-hemisphere functions, such as analysis and
learning, to process preverbal experiences, negative affects, and other
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unconscious phenomena associated with the right hemisphere. It was

previously established that the psychotherapeutic potential of meditation
was its ability to access the unconscious (Epstein, 1990a) and unveil
repressed material (J. Miller, 1993). At present no neurological studies
have been conducted to test this hypothesis.
What relevance do these neurological findings of meditation have
on Western psychotherapy? For one, they are in agreement with the
traditional Indian accounts of Buddhagosha (1991) and those contemporary
scholars that have examined his work (Goleman, 1988; Thurman, 1984)
that mindfulness is a conscious activity that includes intuitive and direct
perceptual experience of reality, rather than the intellectual, rational, and
cognitive capabilities alone. Sustained mindfulness represents a shift from
our ordinary hyper-reactive state to a more emotionally relaxed,
perceptually receptive state. This cultivated state may be useful to the
goals of psychotherapy because, for example, it can provide a
nondefensive frame of mind conducive to the examination of repressed
feelings and memories. More importantly, if skill in mindfulness were
further developed it could eventually deepen into a sustained baseline
trait of consciousness characterized as more relaxed, deautomatized, and
less habituated (B.A. Wallace, 2005).

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PET, fMRI, and EEG Studies

Two relatively new neuroimaging techniques, positron emission
tomography (PET) and functional magnetic resonance imaging (fMRI),
provide distinct tools for researchers exploring activity within the brain.
PET can follow differences in brain activity over a course of a meditative
session, while fMRI can examine more thoroughly a single moment of
meditative experience, even including the release of neurotransmitters
such as dopamine. Gremer et al. (2005) contrasted these techniques with
the much older electroencephalogram (EEG) capability, stating,
EEG signals have millisecond resolution but poor spatial
resolution. These images give the scientist only a general brain
region in which the activity is occurring and cannot reliably detect
activity from deep subcortical structures such as the amygdala and
or hippocampus. The use of EEG has allowed scientists to identify
dynamic changes in brain activity during meditation in a way that
reflects the types of activity that are occurring (alpha, gamma, or
beta waves) not just the regions that are active. Furthermore, EEG
has an advantage over PET and fMRI, in that it allows researchers
to assess brain activity in a quiet and relatively naturalistic setting.
(p. 234)
Lazar et al. (2000) used fMRI to monitor effects of Kundalini yoga
(a concentration practice) and found that activity steadily increased in
brain regions involved in attention and physiological modulation while
activity decreased in the sensory cortex. This supported subjective
accounts that concentration style meditation involved a withdrawal of
attention from external and sensory stimulation.
In a study involving PET of another concentrative practice known
as Yoga Nidra, Lou et al. (1999) found decreases in brain regions involved
in executive control, emotional processing, and motor planning. In their
follow-up study (Kjaer et al., 2002), these same researchers found
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increased levels of dopamine released in the striatum, which was

consistent with subjective accounts of feelings of relaxation and decreased
arousal. In another study of concentration meditators, Newberg et al.
(2001) found decreases in parietal lobe activity, a region involved in
sensory integration and maneuvering in space. Decreased activity in this
region was consistent with subjective reports of meditative experience of
the higher jhanas of the formless realm, and of mystical accounts of out-ofbody experiences and loss of time and space.
In contrast to these studies examining the effects of concentration
meditation (CM), Davidson et al. (2003) conducted a randomized,
controlled trial on the effects of MBSR on brain and immune function with
healthy employees in a work environment. EEG data was collected at
baseline, immediately after, and at 4 months post intervention. Following
the 8-week mindfulness program all subjects were vaccinated with
influenza vaccine. The study also differed from most other brain studies
by shifting its investigative emphasis away from meditative effects during
a single session to those that could be more enduring.
The Davidson et al. (2003) study indicated that over a period of
time, mindfulness meditators achieved greater levels of left-sided
activation of anterior regions in the brain, compared to the control group.
It had been previously established that activation in these regions was
associated with decreased anxiety and increased positive affect (Davidson
& Irwin, 1999). These findings were the first to document significant
changes in anterior activation asymmetry as a function of meditation
training (p. 9). The neurological benefits of mindfulness meditation
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become clearer when viewed in combination with previous evidence

(Davidson, 2000) that left-sided anterior activation increased recovery
rates from stress related conditions and negative provocations.
The Davidson et al. (2003) study was the first to show increases in
immune function as a result of mindfulness meditation, as indicated by
the rapid peak rise of antibody titers among the experimental group post
vaccination. The study suggests that there is a high correlation between
left-side brain activation and increased immune function. The researchers
indicated that the small sample size and limited statistical data made their
findings provisional and that further investigation was needed. But they
did conclude that a short training program in mindfulness meditation
could have important health-promoting biological and neurological
effects.
The study lends weight to the assertion that mindfulness
meditation differs from concentration in terms of neurological effects.
Furthermore, it appears that mindfulness meditation might help bridge
the mind/brain divide by providing a technology that shifts mental states
from stress-reactive to tranquil, and affective states from anxious to
enriched and pleasurable. The authors showed that these shifts in
psychological disposition influenced neurobiology by boosting immunity
and rehabilitating long-term neurological degradation, thus hastening
recovery from environmental challenges. According to Cahn and Polich
(in press), the Davidson et al. (2003) study indicated that
these outcomes may reflect the relative activation of left and right
prefrontal cortices, which indexes emotional tone and motivation
such that left-greater-than-right alpha power is associated with
greater right frontal hemisphere activation (Coan & Allen, 2004;
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Davidson, 1988, 2003). In this framework, appetitive and approachoriented emotional styles are characterized by a left-overright
prefrontal cortical activity, whereas avoidance and withdrawaloriented styles are characterized by right-over-left prefrontal
cortical dominance (Davidson, 1992; Davidson, Ekman, Saron,
Senulis, & Friesen, 1990; Davidson & Irwin, 1999). Normal variation
of positive versus negative affective states suggests left dominance
for happier states and traits, with left-over-right frontal
hemispheric dominance primarily related to the approachwithdrawal spectrum of emotion and motivation (Davidson,
Jackson, & Kalin, 2000; HarmonJones, 2004; Harmon-Jones & Allen,
1998; Wheeler, Davidson, & Tomarken, 1993). In sum, meditation
practice may alter the fundamental electrical balance between the
cerebral hemispheres to modulate individual differences in
affective experience, with additional studies warranted to assess
this possibility. (p. 15)
Neuroplasticity theory (A. Damasio, 1994) suggests the possibility
that by cultivating positive states such as happiness (sukha) and care
(karuna) overtime, they can become more firmly ensconced personality
traits through repeated learning and reinforcement, which ultimately
transforms neural networks in the brain (Begley, 1986; Schore, 2003;
Siegel, 1999; Solms & Turnbull, 2002). The opposite findings have already
been established, whereby negative character traits and adverse emotions,
such as self-involvement (Graham, Scherwitz, & Brand, 1989; Scherwitz,
Graham, & Ornish, 1985; Scherwitz, Graham, Grandits, Buehler, &
Billings, 1986), anger (Ornish et al., 1990), and hostility (Williams, 1989),
release a toxic mixture of hormones within the nervous system, including
cortisol and adrenocorticotropin, which over time has been found to
impinge neural growth (Sapolsky, 2003), decrease cortical volume
(Rosenzweig & Bennett, 1996) and correlate highly with heart disease
(Ornish et al., 1998; Williams et al., 1999) depression (Teasdale et al., 2000),
and death (Lee, Ogle, & Sapolsky, 2002; Sapolsky, 1998, 1999).
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Lutz et al. (2004) also suggested that increased attention and

positive affect were skills that could be acquired through mental training.
They examined the neurological effects of meditation produced by two
groups with varying levels of meditative experience. Compared to novice
meditators, the highly trained Tibetan Buddhist meditators, who had
acquired over 10,000 hours in meditation, had markedly higher
amplitude, and long-range global gamma synchrony in bilateral frontal
and parietal/temporal regions. An increase in gamma synchrony was also
observed in baseline measurements (before meditation) that became
enhanced and more global during meditation in the trained Tibetan
meditators. Gamma-band frequencies were found to correspond with
attention, working memory, learning, conscious perception, and the
dreaming state (Fries, Reynolds, Rorie, & Desimone, 2001).
The neurological changes produced by the expert meditators added
further support of an electrophysiological correlate of consciousness. The
fact that trained Tibetan meditators had baseline increases in gamma
synchrony and amplitude suggested long-term changes in their brains as a
result of years of meditation practice. One might speculate that as a result
of meditative-induced development in specific brain regions, these monks
functioned at a more highly conscious baseline state, and achieved even
greater intensity of conscious awareness during meditation. The authors
(Lutz et al., 2004) refuted the concept that these neurological effects were
caused by preexisting differences in the sample. Their correlation analysis
revealed that hours of practice significantly predicted gamma-band
synchronization not age, culture of origin, or demographics. Once
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again, the study confirmed a rate-proportionate (dose-response)

characteristic of meditation.
A particularly astonishing finding highlighted the study. While
abiding in state of loving kindness for all beings during a meditation
practice referred to as nonreferential compassion (dmigs med snying rje, in
Tibetan), the Tibetan monks showed the highest amplitude gamma
activity ever reported in a nonpathological participant. In a recent press
interview, one of the researchers described the readouts of a monks level
of brain activity and state of happiness to be right off the curve (Savory,
2004).
Taking advantage of fMRI, researchers identified specific regions
that were active during compassion meditation. In almost every case, the
enhanced activity was greater in the brains of the monks than in those of
the novices. Increased activity in the left prefrontal cortex, which is the
seat of positive emotions such as happiness, joy, and enthusiasm, was
simultaneously observed with decreased activity in the right prefrontal,
the seat of negative emotions, anxiety, and sadness (Goleman, 2003a,
2003b). A sprawling circuit that switches on at the sight of suffering also
showed greater activity in the monks. So did regions responsible for
planned movement, as if the brains of the monks were primed to respond
to the distress of others. Again the neurological effects of distinct practices
must be stressed. The nonreferential compassion practice of this particular
Tibetan Buddhist monk under observation incorporated skill in
attentional control (concentration) to maintain the centrality of theme of

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compassion, yet retained an alert receptivity (mindfulness) to the plight of

others.
The implications of a feedback loop in which brain matter and
function can be altered through intention and reinforced through
meditative training are extremely significant. Equally important is the
shift in the paradigm of the health sciences to include concepts of positive
affect and well-being, rather than solely focusing upon disease and
pathology. This paradigm shift is being pioneered in part by Richard
Davidson (1976, 1988, 1992, 1994, 2000, 2003; Davidson & Goleman, 1977;
Davidson, Ekman, Saron, Senulis, & Friesen, 1990) as well as various other
researchers (Ekman et al., 2005; Urry et al., 2004) who are promoting
concepts, such as flourishing, resilience, and well-being in response to
their findings that meditation can help cultivate positive human qualities.
Davidson and colleagues of the Labratory for Affective Neuroscience at
the University of Wisconsin-Madison, have been awarded a $15 million
grant to study the positive effects of meditation using Tibetan Buddhist
adepts as their sample (Savoy, 2004). In a recent interview (Savory, 2004)
Davidson stated that
the monks, we believe, are the Olympic athletes of certain kinds of
mental training, these are individuals who have spent years in
practice. To recruit individuals who have undergone more than
10,000 hours of training of their mind is not an easy task and there
aren't that many of these individuals on the planet. (para. 22).
It is an extremely rare and fortunate opportunity to examine the
brains of experts who may shed light on the outermost ranges of positive
human potential. In Savorys (2004) interview, Davidson stated that, "Our
work has been fundamentally focused on what the brain mechanisms are
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that underlie these emotional qualities and how these brain mechanisms
might change as a consequence of certain kinds of training (para. 36).
Davidson refuted the view that happiness was a byproduct of fortunate
environmental circumstance and proposed that
rather than thinking about qualities like happiness as a trait we
should think about them as a skill, not unlike a motor skill, like
bicycle riding or skiing. These are skills that can be trained. I think
it is just unambiguously the case that happiness is not a luxury for
our culture but it is a necessity. (Savory, 2004, para. 30)
With incidents of stress-induced, so-called diseases of civilization on
the rise, Davidson concluded the interview suggesting that, "the human
and economic cost of psychiatric disorder in Western industrialized
countries is dramatic, and to the extent that cultivating happiness reduces
that suffering, it is fundamentally important" (Savory, 2004, para. 28).
Neuroplasticity
In recent years, research on the mechanisms of stress has led to a
new understanding of the origins of mental illness (Appley & Trumbull,
1986; Fawcett, 1992; Rabkin, 1982; Sapolsky, 1998, 1999; Schmidt et al.,
1997). Loizzo (2000) reported that the triphasic sequence of events
observed in the fight-flight response to stress included unrealistic
appraisal, fear-based cognition, adverse affect, and hypothalamicpituitary-adrenal activation. There was strong evidence implicating stress
in the production of long-term neurological consequence if the triphasic
sequence continued to go unchecked. Repeated activation of this triphasic
stress sequence resulted in decreased neurogenesis, long-term
degradation of neural tissue, and decreased cortical volume. It also might
be involved in the development of psychological trauma, anxiety, and
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mood disorders (Sheline, Wang, & Gado, 1996; Yehuda, 1997). The
allostasis model conceived in mind-body research may shed light on the
pathological effects of uncontrolled stress. According to Shulkin,
McEwen, and Gold (1998),
Allostasis means achieving stability through change, and it refers in
part to the process of increased sympathetic and hypothalamic
pituitary adrenal activity to promote adaptation and to reestablish
homeostasis. Allostasis also highlights our ability to anticipate,
adapt or cope with impending future events. . . . [W]hen allostatic
systems remain active they can cause wear and tear on tissues and
accelerate pathophysiology a phenomenon we have called
allostatic load. . . . There are three types of allostatic load: 1)
Frequent over stimulation by frequent stress, resulting in excessive
hormone exposure; 2) failure to turn off allostatic responses when
they are not needed or inability to habituate to the same stressor,
both of which result in overexposure to stress hormones; 3)
inability to turn on allostatic responses when needed, in which case
other systems (e.g., inflammatory cytokines) become hyperactive
and produce other types of wear and tear. (p. 220)
This model helps to conceptualize the neurological processes
involved in, and affected by, the exposure to stress. Two developments in
cognitive neuroscience offer encouragement that there are potential
solutions to the issues caused by allostatic load. First, there is evidence
that the nervous system is more flexible and dynamic than was previously
conceived (A. Damasio, 1994). The last century of biological and
neurological researchers consistently maintained that the brain and central
nervous system were largely hard-wired and rarely changed after an
initial period of development (Reiser, 1984). New evidence seems to
indicate the contrary, and, as Loizzo (2000) pointed out a
greater dialog with neurobiology has made psychotherapy
researchers aware that learning plays a formative role in the
development of brain structure and function, and that its substrate
neuroplasticity, is a pervasive and continuous property of neural
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systems, rather than the exception to a rule of genetically

determined hard-wiring. (p. 149)
Neuroplasticity refers to structural and functional changes in the
brain, which have been brought about by training and experience. The
brain is the organ that is designed to change in response to experience.
Neuroscience and psychological research over the past decade on this
topic have burgeoned and are leading to new insights about the many
ways in which the brain and behavior change in response to experience
(Davidson, 1994). This basic issue is being studied at many different
levels, in different species, and on different time scales. Yet all of the work
invariably leads to the conclusion that the brain is not static but rather is
dynamically changing and undergoes such changes throughout one's
entire life (Damasio, Grabowski, Frank, Galaburda, & A. Damasio, 1994).
Therefore, damage caused by allostatic load is not necessarily irreversible,
as the nervous system may continue to learn, grow, change, and heal itself
throughout a life span if an individual continues to receive positive
stimulation and enrichment (Rosenzweig & Bennett, 1996; Swaab, 1991).
Further research into meditation and the biological mechanisms of
stress/emotional reactivity would provide needed substantiation for
theories implicating such practice in the functional reorganization of
stress-related limbic structures (Esch, Guarna, Bianchi, Zhu, & Stefano,
2004).
The second encouraging development is that there is some
indication as to what might provide this continued positive stimulation or
enriched environment. This is where developments in meditation
research and mind-body medicine may have their greatest impact (Loizzo,
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2000). The state and traits produced by meditation may nourish the brain,
enable it to retain its pliable quality, and promote its restorative capacity
(Begley, 2004; Davidson, Jackson, & Kalin, 2000). In Chapter 3 of the
present study, it was posited that mindfulness meditation accesses the socalled love-growth learning response of the mammalian brain, which
counteracts the fight-flight stress response of the defensive reptilian brain
(Loizzo, 2000, 2006b). It has also been previously established that
meditation is a catalyst for learning similar to free association and
cognitive restructuring, and it has been linked to neural plasticity
(Delmonte, 1990b; Kabat-Zinn, 1992; Loizzo, 2000). Therefore, one may
posit that meditation is not only useful in deactivating the stress response
during an acute triggering situation, thereby arresting future neural
damage; but it may also play a crucial role in rehabilitating and repairing
the long-term damage associated with chronic stress and allostatic load.
According to Loizzo (2000),
Current research indicates that meditation techniques provide
teachable methods for consciously changing not just the
psychological software of fundamental habit patterns, but even
the physical hard wiring of neural networks and wetware of
neurotransmitters, hormones and other chemical messengers.
Given what neuroscience has been discovering lately about the
central organizing role of mind-brain-behavior patterns in health,
modern medical science is beginning to understand why the
medical systems of the classical world put educational self-healing
methods like meditation at the heart of their theory and practice. (p.
147)
Summary
The present review of the neurological effects of meditation
indicates considerable discrepancy among results, a fact most likely
related to the lack of standardized designs for assessing meditation effects
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across studies, the many types of practices assayed, and a lack of technical
expertise applied in some of the early studies. Given the wide range of
possible meditation methods and resulting states, it seems likely that
different practices will produce different psychological effects and also
that different psychological types will respond with different
psychobiological alterations.
EEG meditation studies have produced some consistency, with
power increases in theta and alpha bands and overall frequency slowing
generally found. Additional findings of increased power coherence and
gamma band effects with meditation are starting to emerge.
Neuroimaging results are beginning to demonstrate some consistency of
localization for meditation practice, with frontal and prefrontal areas
shown to be relatively activated. These outcomes appear to index the
increased attentional demand of meditative tasks and may be associated
with mindfulness-based learning and analysis.
However, what is strikingly absent from the literature is the lack of
attention paid to neural correlates of ones subjective experience of self,
particularly during meditative moments. A greater understanding of the
brain functions involved in ones self-experience, would be a prerequisite
to future examinations of so-called reproducible experiences of
selflessness and boundless compassion. We have yet to isolate or
characterize the neurophysiology that makes explicit how meditation
induces altered experience of self, in contrast to the Buddhist tradition
wherein this is provided in great detail through the use of valid cognition
or first- person methodology. Studies of the reported nondual
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absorptive experience (samadhi) that merges self with the phenomenal

world are also needed to establish this state effect. Prospective
longitudinal assessments are required to establish trait effects that may
reflect subtle neural alterations underlying the shift in the locus of selfexperience and the development of stable unchanging awareness.
This review determined that despite appearing to be similar to rest,
relaxation, or sleep, in terms of decreased arousal, concentrative training
is a consciously cultivated state that prepares the practitioner for
contemplation, mindfulness and analysis. While in this state of relaxed
alertness, the intuitive function of the brains right hemisphere and
investigative function of the left hemisphere are heightened and perhaps
brought into synchronization, leading individuals toward deep structural
learning, growth, and change.
With advances in neuroplasticity research, clinicians in the field are
now beginning to see the potential long-term benefits of mindfulness
meditation. A decade ago, researchers might have been satisfied
conceptualizing mindfulness meditation as an alternative technique for
stress reduction. Now, it may be viewed as a learning tool for cognitive
retraining, affect tolerance, and reconfiguring the neural wiring of deeply
ingrained outlooks, attitudes, and behaviors, as well as enriching and
stimulating the natural healing capacity of their nervous system. Equally
useful as a preventive measure to lessen acute stress responses and its
repercussions, mindfulness meditation has the potential to be a
rehabilitative method to repair accumulated damage caused by allostatic

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load. Let us now examine the psychological effects of mindfulness and its
efficacy as a clinical intervention for mental illness.
CHAPTER 6: MINDFULNESS MEDITATION IN CLINICAL
PSYCHOLOGY

Introduction
The present chapter focuses on the psychological effects of
mindfulness meditation and its potential value as a clinical intervention in
psychotherapy. The initial interest in meditation during the late 1950s had
scientific researchers identifying its physiological correlates, and later its
physical health benefits, in a medical context. In 1960 the now classic Zen
Buddhism and Psychoanalysis (Fromm, Suzuki, & De Martino, 1960)
provided one of the first cross-cultural, theoretical examinations of these
two traditions, heightening academic interest in comparative psychology.
This gave rise to a productive dialogue that focused on the integration of
ancient Buddhist contemplative practices with Western psychotherapy
and psychiatry (Claxton, 1986; Epstein, 1995; Milano, 1998; Pickering,
1997; Segall, 2003; Snaith, 1998; Watson, 1998; Watson, Bachelor, &
Claxton, 2000).
By the mid-1980s research on the cognitive and psychological
correlates of meditation began to take place, with specific interest in its
application in a psychotherapeutic context. Early reports of the utility and
effectiveness of meditation in clinical contexts were primarily single-case
studies. These reports examined the use of meditation for a broad range of
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clinical issues, yet these findings were preliminary and in need of further
substantive research and clinical trials. Mindfulness meditation was
shown to reduce: haparanoia (Boornstein, 1983), neurosis (Epstein, 1990a),
obesity (Weldon & Aron, 1977), stuttering (McIntyre, Silverman, &
Trotter, 1974), claustrophobia (Boudreau, 1972), anxiety (Shapiro, 1976),
insomnia (Miskiman, 1977a, 1977b), hypertension (Benson, Rosner, &
Marzetta, 1973; Simon, Oparil, & Kimball, 1977), asthma (Wilson,
Honsberger, & Chiu, 1975), drug abuse (Benson & Wallace, 1972;
Delmonte, 1985; Hayes et al. 2002), alcohol abuse (Shafii, Lavely, & Jaffe,
1975), and various other behavior disorders (Bloomfield, 1977; Glueck &
Strobel, 1975; Hayes, Wilson, Gifford, Follette, & Strosahl, 1996; Kelly,
1996; Kutz, Borysenko, & Benson, 1985; Lukoff, Turner, & Lu, 1993; Rubin,
1985, 1991, 1996).
With the emergence of meditation in clinical context for the
treatment of a wide range of mental health issues, questions were raised
regarding its compatibility with Western approaches and methodologies.
Does mindfulness meditation lead to improvement or difficulties in
psychological adjustment? How does one compare Indian meditation
practices and Western therapies, such as free association? Are there
dangers in introducing introspective, self-regulatory strategies to patients
with limited ego-strength or advanced mental illness? Does meditation
offer access to dimensions of the human experience that are largely
untouched by Western therapy? Is there a place for a spiritual practice in
a therapeutic context?

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In an attempt to address these questions, the present chapter

examines and compares the metatheory of Buddhist and clinical
psychology. The chapter then reviews articles that compare the
techniques of mindfulness meditation and free association. It also
discusses the possible complications that might arise when using
meditation in a therapeutic context. The chapter concludes by reviewing
outcome data from studies involving mindfulness-based psychotherapies,
and assessing the clinical value and efficacy of these novel approaches.

Buddhism and Clinical Psychology

According to cross-cultural, cross-disciplinary perspectives of some
researchers (De Silva, 2000; Epstein, 1995; Goleman, 1981; Loizzo, 1997,
2000, 2006b; Snaith, 1998; Thurman, 2004), Freud located the source of
psychopathology in unrestrained unconscious impulses. He viewed the
neurotic individual as conditionally reactive to sexual desire (eros) and
death aggressive (thanatos) instincts, and in need of bringing these forces
into conscious regulation. He postulated that the development of
conscious awareness and mature defenses would enable individuals to
control their impulses and negate dysfunctional behaviors, thereby
civilizing them. In Freuds final estimation, however, the necessary
exchange of impulse indulgence for social acceptance was a painful
process that resigned individuals to the inevitability of ordinary human
misery (Freud, 1961). As Thurman (2004) suggests,

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Western psychology developed during an era of

industrialization. Freud and Jung lived in the wealthier societies of
central Europe. Members of the middle class finally had a little
time and money to explore their general state of being. When their
interiors were maladjusted or abused or neglected, they could find
someone to work with them. . . . But their [psychologists] main
purpose was only to re-adapt these misfits back into the machinery
of industrialized society so that their patients could work, function
an be normal again. As Freud himself said, his therapy was
designed to help people get rid of neurotic suffering so they could
get back to ordinary suffering. There was never any mention of
complete freedom from suffering as a definition of health, or even a
livable option. (p. 38)
According to De Silva (2000), roughly 2,500 years before Freud, the
Buddha also located the source of human suffering in unconscious
impulses. He similarly determined that unrestrained desire and
aggression impelled individuals toward repeatedly experiencing anguish
and disappointment (dukkha). Some Buddhist-oriented clinicians (Epstein,
1995; Loizzo, 1997) have argued that Freud did not take his analysis of
human drives deep enough. For beyond the two secondary impulses lay a
primary drive, previously described as the self-reification habit, which
operates out of fundamental misknowledge (avidya) (Loizzo, 2000).
Individuals are propelled to grasp and avoid, to engulf or destroy, based
on their own narcissistic preoccupations, and the erroneous beliefs in their
own separate, autonomous, and permanent condition (Loizzo, 1995).
According to Goleman (1976), in meditation
a set of healthy mental properties reciprocally inhibits an unhealthy
set. In light of Abhidharma and empirical findings, applications of
meditation are suggested for inducing an optimal mode of
responsiveness to environmental demands, and as a
complimentary adjunct to psychotherapy. (p. 41)

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Freud discovered that the untrained mind is beyond our control,

largely maladaptive, confined by habitual processes, dominated by sexual
and aggressive impulse, and operates unconsciously from a position of a
false view of reality. The key to the Buddhist retraining of mind is to
replace these mental factors with those more conducive to wellness and
clarity. Goleman (1976) explains:
Just as in systematic desensitization where tension is supplanted by
its physiologic opposite relaxation, healthy mental states are
antagonistic to unhealthy ones, inhibiting them. In the dynamic of
this system, the presence of a given factor disallows the arising of a
specific unhealthy factor. The major healthy factor of insight or
understanding clear perception of the object as it is
suppresses the fundamental unhealthy factor of delusion.
[Mindfulness sustains insight], and where there is insight delusion
cannot be. (p. 42)
According to Western Buddhist proponents (Epstein, 1995; Loizzo,
1997; Thurman, 1998, 2004), because Freud did not locate and address the
original impulse of self-involvement, his therapeutic system falls short of
providing lasting happiness and relief. As we have seen in the Third
Noble Truth, complete liberation (nirvana) from impulsive habit and
fundamental ignorance is not only possible, it is every sentient beings
potential (tatagathagarbha) and lifes purpose to actualize. The fact that
Buddhism and clinical psychology address different levels of negative
impulse and have differing methodologies has caused great confusion in
the literature regarding their compatibility.
Generally speaking, the literature contains two fundamentally
opposing views. The sequential view, posited by early researchers,
(Bacher, 1981; Engler, 1984; Goleman, 1976; Russell, 1986) maintained that
meditation and clinical psychology differed greatly with respect to how
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they affected the ego. These researchers insisted that psychotherapy and
meditation techniques could only be used sequentially, according to an
expanded personality development model conceived in transpersonal
theory (Walsh & D. H. Shapiro, 1983; Walsh & Vaughan, 1993; Wilber,
1977, 1980a, 1995, 1996). In contrast, the simultaneous view, posited by
more recent researchers (Epstein, 1986, 1995; Hirst, 2003; Loizzo, 2000)
found Buddhist meditation to be a coherent therapeutic system capable of
addressing similar issues as do traditional, cognitive, and dynamic
therapies. As such, mindfulness could be prescribed simultaneously with,
or independent of, conventional approaches as a means to facilitate
psychological adjustment and relief from suffering.
Examples of conflicting reports include Deikman (1982), who saw
meditative and psychotherapeutic strategies as being focused on different
aspects of the individualmeditation analyzing consciousness itself, and
psychotherapy analyzing the contents of consciousness. According to the
author, Buddhist approaches attempted to eliminate craving altogether by
exposing the futility of the attempt to satisfy them; while Western therapy
focused on the fulfillment of personal desires, the gratification of the
object self (p. 81). In Deikmans (1982) view, meditation was an effective
adjunct to the process of therapy rather than as a replacement. Vassallo
(1984) explained that by targeting clinging and ignorance, Buddhist
meditative practices helped to eliminate the individualistic preoccupation
that was at the root of suffering. Western strategies aimed only at coping
with the manifestations and symptoms of suffering. Bradwejn, Dowdall,
and Iny (1985) strongly agreed that the goal of meditation, the realization
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of the illusionary nature of the self, was irreconcilable with the goal of
therapy, which was the development of a cohesive ego.
Mindfulness Meditation Compared to Psychotherapy
Kutz et al. (1985) conducted a thorough comparative analysis of
mindfulness and the psychotherapeutic technique of free association, both
of which involved witnessing mental activity while maintaining an
uncritical, nonjudgmental position. They found that mindfulness and free
association differed in the way in which mental material was handled, in
that free association attempted to interpret the meaning while
mindfulness continuously strived to observe the flow of consciousness. In
this way way, they concluded that free association enabled individuals to
attain a healthy perspective by allowing them to confront unconscious
dynamics (repressed negative experiences and defense mechanisms) that
arrested psychic development. Conversely, mindfulness led to health
when adherents examined perceptual-cognitive habit patterns that
reinforced negative affect. According to Kutz et al. (1985),
the repeated experience of recognizing the patterns of ones mental
process has therapeutic value of its own. The continuous activity of
categorizing and decategorizing of mental events gradually
provides insight and understanding into how mental schemes and
programs are created. Therapies break the hold of past
conditioning on present behavior. Meditation tries to alter the
process of conditioning per se. (p. 5)
Another way researchers compared Buddhist meditation and free
association was by defining these disciplines as either covering or
uncovering (Russell, 1986). In the covering [techniques], unconscious
material that produces problems by threatening to emerge is suppressed.
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These methods are often used in dealing with crisis, short-term therapy,
and patients who are incapable of handling their unconscious emotions
(p. 116). Uncovering was defined as a technique used to enable patients to
face psychological material and the defense mechanisms that kept them
bound in the unconscious. Free association was the classic example of this
technique, exposing repressed material and then helping patients
integrate this material into a realistic self-image.
According to Russell (1986), in the two types of Buddhist
meditation, concentration styles were seen as covering techniques because
the meditator nonjudgmentally dismissed all mental content except for the
chosen subject. Mindfulness was seen as having two aspects: 1) an
uncovering technique, in which an open focus allowed for the emergence
of repressed material into conscious awareness; and 2) a covering
technique because no analysis, working through, or integration of, the
subject matter occurred. Instead, practitioners remained present and
mindfully aware without actively participating in the stream of
consciousness. Engler (1984) concurred with these definitions, which were
also identified by Goleman (1976) who explained that the various
psychotherapies were directed towards the content of consciousness,
while meditation was directed at consciousness itself.
Hirst (2003) reported that the practice of mindfulness had many
features in common with free association. These included focusing on the
contents of consciousness without prior censorship, judgment, or
interpretation; accessing instinctual wishes and unconscious impulses;
and allowing the forces of repression and suppression to relax. Delmonte
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(1990a, 1990b) also observed that mindfulness meditation was comparable

to free association; since both increased insight and enabled individuals to
integrate the perceptual, cognitive, and behavioral aspects of their
personalites. Both mindfulness meditation and free association thus
opposed repression and promoted health.

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Theoretical Models Combining Techniques

The assumption that Buddhist meditation does not encourage
analysis of unconscious material brings into question its relevance in
psychotherapy. Russell (1986) conducted an extensive review of Buddhist
literature and found no significant recognition of unconscious dynamics,
as described in the West. It appeared to him that mindfulness meditation
and Western psychotherapy possessed completely distinct models of
development and mental wellness, and thus prescribed radically different
technologies. As Engler (1984) pointed out
Buddhist psychology never elaborated a developmental
psychology in the Western sense. It has no theory of child
development. Nor does it have a developmental view of
psychopathology. That is, it does not explicitly place different
levels of mental disorder along a developmental continuum
according to etiology. What Buddhist psychology and practice
appear to do instead is presupposes a more or less normal course of
development and an intact or normal ego. For its practice, it
assumes a level of personality organization where object relations
development, especially a cohesive and integrated sense of self, is
already complete. (p. 39)
This analysis explicitly defined the difference in how the ego was
perceived and defined by Buddhist psychology as compared to how it
was seen in Western psychology. Generally, the latter attempts to
rehabilitate a defective, nonfunctioning personality, or to correct abnormal
or preformed ego constructs. Buddhist psychology aims at optimizing
personality by deconstructing the normal, established ego. Engler (1984)
underscored this distinction:
The therapeutic issue in the clinical treatment of the severe
disorders [infantile autism, symbiotic and functional psychosis and
borderline conditions] is how to regrow a basic sense of self, or
how to differentiate and integrate a stable, consistent and enduring
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self-representation. The therapeutic issue in Buddhist practice is

how to see through the illusion or construct of the self (attaditthi), how to dis-identify from those essential identifications on
which experience of our personality is founded. (pp. 30-31)
Engler (1984), Russell (1986), and Goleman (1976) reflected the
general consensus that each method maintained its own distinct benefits
and limitations. According to these researchers, Western psychotherapy
was most effective at early developmental stages in the formation of a
healthy and stable ego; but had neither the conceptual framework nor the
technology to go beyond this point. These authors pointed out that Freud
assumed that the objective of psychoanalysis was to bring individuals to a
state where they could cope with human suffering.
Interestingly, in the Buddhist fourfold medical model the
realization of dukkha, or normal human suffering, is seen as the starting
place, with the therapeutic path proceeding from there. Buddhism
considers normality (the misperception of a rigid and fixed personality) to
be a form of pathology and provides a framework and specific technology
to expand limited ego defining boundaries. According to Engler (1984),
who focused on the limitations of the Western approach,
The very attempt to constellate a self and objects that will have
some consistency and continuity in time, space and across states of
consciousness emerges as the therapeutic problem. The two great
achievements in the all-important line of object relations
development identity and constancy still represent a point of
fixation or arrest. . . . [From the Buddhist] perspective what we take
as normality is a state of arrested development. Moreover it can
be viewed as a pathological condition insofar as it is based on
faulty reality testing, inadequate neutralization of the drives, lack
of impulse control, and incomplete integration of the self in relation
to the object world. (p. 50)

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The general consensus among researchers is that the divergent strengths

and limitations in each system do not make them incompatible or
mutually exclusive, as Goleman (1976) explains:
Consciousness is the medium, which carries the message that
composes experience. Psychotherapies are concerned with these
messages and their meanings; meditation instead directs itself to
the nature of the medium, consciousness. These two approaches
are by no means mutually exclusive, but rather complementary. A
therapy of the future may integrate techniques from both
approaches, possibly producing a change in the whole person more
thoroughgoing and more potent than either alone. (p. 53)
Most articles noting the distinctions found that there was some
compatibility based upon the concept that each addressed essential
aspects of treatment that the other did not. In so doing, a new
cartography of personality development that incorporated insights of both
Western and Buddhist psychology was proposed by several transpersonal
theorists (Engler, 1984; Walsh & D. H. Shapiro, 1983; Walsh & Vaughan,
1993; Wilber, 1977, 1995, 1996). These authors demarcated the transition
from preegoic stages to egoic stages to transegoic stages also described as
prepersonal to personal to transpersonal (Wilber, 1977).
The Sequential Model
Bacher (1981), seeing that mindfulness meditation and Western
psychology aimed at different types of ego-development, recommended a
sequential approach in which psychotherapy preceded meditation, a
process which he defined as more beneficial than a blended approach.
According to this view, it was necessary to respect ones developmental
tasks as defined by existential-humanistic therapy. Self-identification,
emotional expression, ego development, and increase in self-esteem were
all necessary before individuals could productively undertake the
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demands of meditation, especially given the fact that the goal of

meditation was the disassociation from personal emotions and egoic
concerns. Meditation taught the skills of attention and equanimity, a state
of inner harmony and balance, and a complete transcendence of the
personal concerns that are the focus of psychotherapy. According to
Bacher, keeping a clear distinction between them maintained the full
integrity and power of each to accomplish its stated aims. He maintained
that, although meditation and Western psychology both performed
corollary functions in regard to the enhancement of well-being, the
intensification of present awareness, and lifting of repression, there were
major theoretical differences that made their separation advisable.
Russell (1986) pointed out in his review of the literature that there
were many indications that a person needed to be fairly well integrated
psychologically in order to meditate effectively. Studies supporting the
sequential view posited that psychotherapy had to precede meditation
because it did not resolve emotional conflict, psychopathology, or
advanced mental illness. Furthermore, a sufficient level of personality
development and ego-strength, fulfilled only by the methods of
conventional psychology, was a prerequisite for subsequent meditative
effectiveness (Jamnien & Ohayv, 1980; Kornfield, Ram Dass, & Miyuki,
1983; Welwood, 1983).
Englers (1984) famous statement characterized the consensus
understanding prevalent in the 1980s and early 1990s:
You have to be somebody before you can be nobody. The issue in
personal development . . . is not self or no-self, but self and
[emphasis added] no-self. Both a sense of self and insight into the
ultimate illusionariness of its apparent continuity and
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substantiality are necessary achievements. Sanity and complete

psychological well-being include both, but in a phase-appropriate
developmental sequence at different stages of object relations
development. (p. 52)
Thurman (2004) opposed this view, but kept quiet until enough
support could build to challenge its basic presupposition. At a conference
in the early eighties hosted by prominent psychologists Thurman (2004)
recounted the following:
Western psychology helps somebody who feels they are nobody
become somebody, and Buddhist psychology helps someone who
feels they are somebody become nobody. When I first heard this, I
was at an Inner Science conference with the Dalai Lama.
Everybody laughed, applauded, and thought it was a great insight.
The Dalai Lama just looked at me and kind of winked and was too
polite to say anything. I started to jump up to make a comment,
but he stopped me. He told me to be quite and let them ponder it
for a few years until they realized the flaw in their thinking.
Because of course that idea is not even remotely correct.
The purpose of realizing your selflessness is not to feel like
you are nobody. . . . [I]t means that you become the type of
somebody who is a viable, useful somebody, not a ridged, fixated,
Im-the-center-of-the-universe, isolated-from-others somebody.
You become the type of somebody who is over the idea of a
conceptually fixated and self-centered self, a pseudo-self that
would actually be absolutely weak, because of being unrelated to
the reality of your constantly changing nature. You become the
type of somebody who is content never to be quite that sure of who
you are always free to be someone new, somebody more. (pp. 5557)
The Simultaneous Model
In agreement with Thurman (2004) there are other researchers and
clinicians in the field who challenged the linear sequential developmental
model and instead proposed a simultaneous model (Epstein, 1986; Loizzo,
2000; Loy, 1992; Segall, 2003). In their view, the simultaneous model was
based upon a more thorough understanding of the traditional Buddhist
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teachings of mindfulness meditation, starting with basic bare attention and

progressing to the advanced stages of analytic insight. These authors
defined analytic insight meditation as a complete therapeutic practice in
and of itself, endowed with the same potential for healing as its Western
counterpart, psychotherapy. As Segall pointed out, while relatively few
authors upheld this view, the research on the simultaneous model was
newer, represented a more thorough understanding of the Buddhist
tradition, and showed greater cross-cultural sensitivity and respect
(Segall, 2003). According to Epstein (1986),
Attempts by theorists of transpersonal psychology to explain the
place of meditation within the overall framework encompassing
western notions of the development of the self often see meditation
as a therapeutic intervention most appropriate for those
possessing a fully developed sense of self. This approach has
been useful in distinguishing transpersonal levels of development
from early, preoedipal levels, but appears to have sidestepped the
issue of how Buddhist meditation practice, for example, could be
seen as therapeutic for psychological issues that have their origin in
the infantile experience. . . . It has been noted that some of those
attracted to meditation have demonstrated narcissistic pathology,
but the role of meditation in transforming narcissistic pathology
has not yet been explored. (p. 143)
While advocating for the simultaneous model, Loizzo (2000) went
a step further by endorsing the independent use of Buddhist practice for a
full range of developmental issues and psychopathology. According to his
research, the three higher trainings (adhisiksya) need no complement, and
have proven efficacy spanning the course of the millennia.
Loizzo (2000) rejected previous assertions by Russell (1986) and
Engler (1984) that defined mindfulness practice as a covering technique.
According to Loizzo (2006b), these early researchers mistakenly thought
that mindfulness was not concerned with integration or working through;
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and, therefore was irrelevant as a prepersonal psychotherapeutic

intervention. Loizzo (2000) explains that the final discipline of
mindfulness is traditionally defined as analytic insight meditation
(vipassana), in which discursive intellect is used before, during, and after
meditation sessions as part of a threefold education (trishiksya) aimed at
long-term therapeutic change (p. 151). Older description of mindfulness
failed to appreciate the potential use and effects at its more advance stages
of insight. Loizzo (2000) continues,
Like free association, [advanced] mindfulness may be best
understood as a cultivated state in which the normal progression
from waking to sleep onset is stopped and exploited for deautomatizing, insight and long-term change rather than as a fourth
state of consciousness. (p. 159)
Phenomenologically, concentration meditation subdues the usual
state of hyper-arousal, while mindfulness keeps the attention receptive
towards any object of consciousness. When a specific subject is chosen for
analysis, skill in concentration retains it indefinitely under observation,
while skill in mindfulness allows for discursive probing without
emotional reactivity.
Mindfulness Meditation and Ego Development
Loizzos (2000) topography of techniques placed Buddhist and
Western psychological schools next to each other rather than at two
distinct ends of a developmental spectrum. In attesting to its integrative
nature, Loizzo pointed out that in the Indo-Tibetan synthesis (ekayana), all
three aspects of Buddhist developmental psychology were practiced
simultaneously, comparable to a family born of one mother (self-analytic
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insight) and three fathers (renunciation, empathic, and impassioned

techniques) (p. 193). Refuting Wilbers (1977, 1980, 1984) transpersonal
vision and linear spectrum models, in which Asian practices such as
Buddhist meditation did not cure prepersonal neurosis, Loizzo (1997,
2000) called for the acknowledgment of the fact that Buddhist psychology
offered a complete therapeutic system. According to Loizzo (2000)
classical analytic psychology and Buddhism were both (a) based on a
coherent philosophy of mind; (b) biologically grounded; and, (c) provided
therapeutic techniques, based on the union of subjective transformation
and interpersonal relationships.
Consistent with Loizzos position, Mark Epstein a Buddhistoriented psychoanalyst and author, finds Buddhism to be a coherent
psychological system capable of addressing prepersonal issues among
others. Epstein (1986, 1995, 1998, 2001, 2005) has identified several ways
in which Buddhist meditation addressed the early developmental deficits
typically associated with the therapeutic work of classical Ego and Self
psychology. Specifically, Epstein (1986) acknowledged the usefulness of
transpersonal developmental models, such as the spectrum of
consciousness (Wilber, 1977), the developmental spectrum of
psychopathology (Wilber, 1984a, 1984b), and the pre/trans fallacy
(Wilber, 1980b) but viewed them as oversimplifications. In his estimation,
the theoretical boundaries between prepersonal, personal, and
transpersonal stages of development were not clearly defined in clinical
practice.

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For example, these transpersonal models viewed narcissism as an

ethno-specific phenomenon endemic to our culture and generalized that
Western psychology was concerned only with lower level or prepersonal
development; while Eastern psychology was concerned only with upper
level or transpersonal development. On the contrary, Epstein viewed
narcissism as a disease of all humanity; and contended that Buddhist
treatments could be beneficial at any level of development.
To emphasize his viewpoint, Epstein (1986) pointed to the fact that
ancient Indian culture possessed an underlying trust in the meditationbased spiritual disciplines to resolve prepersonal conflicts and narcissistic
issues. He also found accounts in traditional Buddhist literature that
people of all psychological dispositions and stages of ego development
attained enlightenment while studying with the Buddha.
In agreement with Epstein, Nyanaponika (2001) also cited a case of
a disturbed mass murderer named Moggallana who would today
probably meet the criteria for having an antisocial personality disorder.
According to the author, Moggallana eventually mastered mindfulness
meditation, became adept at psychic abilities, achieved liberation, and was
chosen by the Buddha to be among his chief disciples. Epstein (1986)
concluded that such a cure was possible because the path of insight led to
the final extinction of defilements (kleshas), including primary narcissistic
disturbances. Goleman (1977) also reported that until the attainment of
sainthood (arhant), the seventh stage on the path of insight, individuals
still struggled with neurotic issues, such as lust, greed, hostility, selfpreoccupation, and self-annihilation. Epstein (1986) stated that there was
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a narcissistic residue left from preoedipal stages of development that

persisted throughout the entire life cycle, but that mindfulness meditation
was suitable in controlling this residue:
Just as this narcissistic residue reverberates throughout the life
cycle, affecting goals, aspirations and intimate relationships, so it
can be seen to reverberate throughout the meditative path, where
psychic structures derived from this infantile experience must be, at
various times, gratified, confronted, and abandoned. (p. 145)
An opposing view was presented by Dubbss (1987) study, which
did not support mindfulness as a means to cope with unresolved
psychological issues. He used interviews and questionnaire assessments
of 30 long-term meditators; in this way, he identified unresolved anger
and narcissistic rage as key elements in their resistance to progress in
meditation. He suggested that psychological and spiritual growth were
linked, but leaned toward a more sequentially developmental model.
Using the same argument that narcissistic tendencies persisted beyond
developmental boundaries, Epstein (1986) contended that meditative
disciplines had the potential to be useful in their psychotherapeutic
treatment and did not have to be relegated only to advanced issues in
personal development.
The Ego Ideal and the Ideal Ego
According to Hanly (1984), advanced mindfulness meditation
addressed problems that stemmed from an imbalance between the
individuals ego ideal and the ideal ego. He pointed out that the ego ideal
identified the source of abstract ideas that the ego had about itself (perfect,
complete, immortal), derived from a long series of denials. He defined the
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ideal ego as embodying the aspiration to transform ones being, arising

from the dissolution of omnipotence created when the mother-child
duality was first recognized. Epstein (1986) explained that the function of
the ideal ego is to assure the self of its own inherent perfection [while]
the ego ideal is associated with a yearning to become something that at its
roots is an internalized image of a lost state of perfection (p. 147).
Epstein (1986) proposed that the two types of Buddhist meditative
disciplines could be used to balance tensions between these two egoic
forces. The concentration type, characterized by pleasurable feelings of
rapture, bliss, expansiveness, and wholeness, could be used to appease the
ego ideal. The mindfulness type could provide a clear perception of
successive mindful moments; and ultimately reveal their impermanent,
insubstantial, and unsatisfying nature. This last process, however, could
initially result in feelings of anxiety and panic that undermined the power
of the ideal ego by forcing the individual to integrate harsh and
dissatisfying dimensions of reality. As Epstein (1986) pointed out,
because advanced Buddhist meditation (vipassana) incorporated both
types of practice simultaneously, it had the capacity to strengthen the ego
ideal when a sense of cohesion was necessary; and, at the same time,
diminish the ideal ego which fueled a sense of self-importance:
the Buddhist texts are very clear about the need for precise
balancing of concentration and insight practices, and, while they do
not use contemporary language of narcissism, it is clear that they
are counseling an approach that balances an exalted, equilibrated,
boundless state with one that stresses knowledge of the
insubstantiality of the self. . . . For meditation may ultimately be
conceptualized as a vehicle for freeing an individual from his own
narcissism, a liberation that is not complete until enlightenment.
Until that point, the individual is subject to the pressures of his
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own narcissistic impulses, and the experience of meditation may be

recruited to satisfy those impulses, at the same time those
experiences force a confrontation with narcissistic attachments. (p.
155)

Reparenting the Ego

Epstein (1995, 1998) proposed another way that mindfulness
meditation could be psychoanalytically viewed and clinically applied in
the service of ego-development, namely that of reparenting oneself in
order to attain greater ego stability and affect tolerance. Personality
disorders in the borderline-narcissistic spectrum of pathology typically
indicate primitive arrests in ego development associated with, among
other things, empathic failures and lack of affect regulation in the motherinfant dyad (Mahler, 1975; Masterson, 1981). As a result, in adulthood
negative emotions are too threatening and overwhelming for such a
patient to endure. Epstein (1995) postulated that mindfulness meditation
could enable individuals to learn how to self-regulate affect, in much the
same way that a mother both attends and attunes to a childs distressing
emotions while maintaining a necessary but nurturing detachment:
It is the openness of a mother who can, as D. W. Winnicott pointed
out in his famous paper The Capacity to Be Alone, allow a child
to play uninterruptedly in her presence. This type of openness,
which is not interfering, is a quality that [mindfulness] meditation
reliably induces (p. 115).
Mindfulness strengthens skills in the observing ego to attend to
afflictive affect without overidentification; while at the same time, it
fosters an attitude of loving kindness (Pali, metta; Skr, maitri) and
acceptance, all of which are needed to create optimal frustration, delay
gratification and build distress-tolerance. According to Epstein (2001), the
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continued practice of mindfulness meditation over time has the capacity

to provide the corrective emotional experience that is required for the ego
to mature and progress. Regarding the mechanisms, he (1995) states,
By separating our reactive self from the core experience, the
practice of bare attention eventually returns the meditator to a state
of unconditional openness that bears an important resemblance to
the feelings engendered by an optimally attentive parent. It does
this by relentlessly uncovering the reactive self and returning the
meditator, again and again, to the raw material of experience.
According to Winnicott, only in this state of not having to react
can the self begin to be. (p. 117)
In his discussion of the psychodynamics of meditation, Epstein
(1995) clarifies his view on what the two respective traditions of
psychology and Buddhism have to offer, and contradicts the conventional
notion that they address different aspects of ego-development.
Much of what happens through meditation is therapeutic, in that it
promotes the usual therapeutic goals of integration, humility,
stability, and self-awareness. Yet there is something in the scope of
Buddhist meditation that reaches beyond therapy, toward a farther
horizon of self-understanding that is not ordinarily accessible
through psychotherapy alone. (p. 130).
In this way, it can be seen that mindfulness meditation has the potential to
resolve issues of ego-cohesion at prepersonal and personal levels of
organization as well as to facilitate transcendence of the limited selfidentification typical at higher levels of neurotic functioning.
Kornfield (1983) also indicated that mindfulness meditation
addressed prepersonal and/or personal conflicts along the developmental
spectrum. He contended that, while Western therapy emphasized
analysis, investigation, and the adjustment of personality, it neglected the
development of concentration, tranquility, and equanimity. In his view,
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concentrative absorption (samadhi) was able to penetrate the surface of the

mind, enabling individuals to use this awareness to cut neurotic issues
(p. 37). Kornfield maintained that meditation was not only a means of
seeking comfort and stability, but of working with inner turmoil in such a
way that profound transformation occurred, which resulted in the death
of the self. Later, however, Kornfield (1989) admitted that meditation was
not a cure-all. He came to believe that in many areas, such as grief,
childhood wounds, communication skills, maturation of relationships,
sexuality and intimacy, career and work issues, and fears and phobias,
Western therapies were better equipped, quicker, and more successful
than meditation alone. Nevertheless, Kornfield suggested using these
forms of therapy in tandem with mindfulness meditation.
Loizzo and other researchers (Epstein, 1995, 2005; Thurman, 1998;
B.A. Wallace, 2001) maintained that Buddhist meditative psychology was
a complete and effective psychotherapeutic system in and of itself.
Contrary to Wilber (1980) and other transpersonal scholars, Buddhism
does not necessarily require Western developmental models to complete
or fill in its theoretical and practical gaps. Furthermore, Buddhist therapy
does not require integration with conventional therapy in order to benefit
patients with prepersonal or personal mental disorders. The need for
Western clinicians and researchers to identify mindfulness meditation as
something distinct from the objectives and goals of psychotherapy, or to
abstract Buddhist techniques and integrate them into their own
conventional therapeutic systems, may reflect either Eurocentric

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insecurity, or perhaps their lack of appropriate exposure to the

metapsychology of the meditative traditions (Thurman, 1984).

Contraindications of Mindfulness Meditation

Complications and Negative Effects
While there are conflicting reports as to how mindfulness meditation
contributes to health, evidence exists supporting its possible side effects.
Epstein and Lieff (1981) provided the most comprehensive review on
psychiatric complications due to its practice. In most of these cases, the
people who experienced negative effects were beginning students,
although late complications in advanced students were reported as well.
According to the authors,
Depolarization and derealization experiences are reported by many
practitioners to be ego-syntonic side effects of their meditations. In
some cases, the feelings may be of such intensity as to necessitate
psychiatric consultation and may, by virtue of their foreignness,
precipitate panic attacks. Anxiety, tension, agitation, and
restlessness may all be paradoxically increased through the practice
of Transcendental Meditation. Exacerbations of depressive affect to
the point of attempted suicide may also follow TM experience.
Perceptions of extreme euphoria accompanied by powerfully
compelling fantasies and MMPI [Minnesota Multiphasic
Personality Inventory] evidence of excessive pressure from
unconscious material followed by unbearable dysphoria is
described in a previously well 38-year old woman following
beginning practice of meditation. Grandiose fantasies evolving
into religious delusions with messianic content are described in a
24-year old male following prolonged meditation in an isolated
environment. Three psychotic episodes, characterized by agitation,
paranoia and suicide attempts, are described in individuals with a
history of schizophrenia participating in intensive meditation
retreats associated with fasting and sleep deprivation. Two
psychotic episodes, in young psychiatric patients with previous
LSD experiences, are described after TM training. (p. 138)
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As Epstein and Lieff (1981) pointed out, it was evident that

meditation could cause profoundly negative experiences in beginning
students. The authors offered two psychoanalytic explanations for these
negative symptoms. The first was that meditation could cause a
regression to primary narcissism; and the second, that individuals lacking
sufficient ego strength were unable to cope with the re-emergence of
repressed material. While Epstein (1986) maintained that meditation had
the capacity to be effective throughout all phases of personality
development, he agreed with Engler (1984) that a precondition for this
effectiveness was having a requisite high level of personality organization.
Bradwejn et al. (1985) also cautioned that before combining therapy and
meditation, the developmental levels of the patient must be carefully
considered. Nevertheless, given the recent physiological understanding of
the relaxation response, it is strange to see such physical side effects as
restlessness and anxiety. More alarming, indeed, are the several cases that
reveal mental instability of some sort in the form of paranoia, anxiety, or
delusion.
Regression to Primary Narcissism
The regression to primary narcissism was first perceived by Freud
(1930) in his critique of mystical experience. In this paper, he identified
states of ecstatic union, or oceanic feelings reported by meditators, as a
regression to infantile stages of development. According to Epstein and
Lieff (1981)
Freud associates this oceanic experience with the most primitive
stage in the development of ego, that of undifferentiation between
self and mother, or primary narcissism. In this view, meditation is
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seen as a libidinal, narcissistic turning of the urge for knowing

inward, a sort of artificial schizophrenia with complete withdrawal
of libidinal interest in the outside world. The spiritual urge,
postulated Freud, seeks a restoration of limitless narcissism, an
evocation of the outgrown mother-child bond employed as a kind
of transitional object designed to protect against the fears of
separateness. (p. 139)
For Freud (1930), the inability to accept solitary existence marked an arrest
in egoic development that could cause psychological complications, such
as maladaptive behavior and dependency. In the Buddhist traditions,
blissful states are seen as potential hindrances, and should be tempered
with the same concentration that induces them.
It can be seen that the above-described experiences of union and
reunion are capable of becoming become protective devices that
individuals use as shelters from the pain of being autonomous. And given
the current phenomenological understanding of the potential euphoric
effects of concentrative meditation, beginning students could also
misinterpret such experiences as an awakening, or union with God; or
unconsciously, as a reunion with their mother. This misinterpretation
could lead to delusion, or paranoia, and to the development of a neurotic
longing for this sense of security.
The Emergence of Repressed Material
Epstein and Lieff (1981) pointed out the inability of some
practitioners of mindfulness meditation to cope with the emergence of
repressed material. Other researchers (Engler 1984; J. Miller, 1993; Russell,
1986) established the fact that, though the psychotherapeutic benefit of
meditation was its ability to uncover unconscious material, at the same
time, it did not offer individuals the means to deal with the material that
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was raised. This left open the possibility that numerous psychological
complications could arise, such as fear, paranoia, anxiety, and even
schizophrenia. The researchers viewed these symptoms as especially
problematic among individuals whose ego was undeveloped, and who
were unable to cope with the emerging content. As Epstein and Lieff
(1981) noted,
the meditation experience offers the opportunity to egosyntonically re-experience and reexamine unresolved conflicts and
drives embodied in material which unfolds. . . . [M]editation can be
seen as an arena in which to uncover primitive material, with side
effects resulting when ego strength is not sufficient to withstand
the force of such material. (p. 139)
These above explanations made clear that the personality development
and ego-stability of the beginning student were crucial in the prevention
of complications.
Review of Adverse Effects
The early psychological literature contained relatively few studies
that reported adverse effects associated with mindfulness meditation
(Carrington, 1977; Epstein, 1990b; Lazarus, 1976; Shapiro, 1992; Walsh &
Roche, 1979). Epstein and Lieff (1981) reviewed psychological
complications corresponding to developmental levels of the meditation
experience. J. Miller (1993) and Delmonte (1990a) studied the potential for
retrauma as a result of the meditative unveiling of repressed memories. In
each of these studies, negative consequences were attributed to the
patients being insufficiently prepared for the emotional work involved in
meditation. In all other cases cited, caution was suggested rather than the
exclusion of the treatment.
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After reviewing a broad range of mind-body therapies currently in

use in medicine and psychiatry, Astin et al. (2003) provided several useful
findings with regards to potential adverse effects. The authors noted that,
unlike pharmacologic trials, there appeared to be no established tools for
assessing adverse events associated with mind-body therapies. Despite
this, they gave examples of several controlled studies which reported that
patients experienced 17% to 31% increase in anxiety during relaxation
meditation, and as high as 53% during mindfulness meditation. This
significant and seemingly ironic increase could have been accounted for
by the fact that mindfulness encouraged continued attendance to
experience, while concentration attempted to bypass or suppress it.
In addition the authors compiled a list of several adverse
experiences noted during meditation including unfamiliar feelings and
sensations, intrusive thoughts, a sense of losing control, floating, muscle
cramps and spasms, dizziness, feelings of vulnerability, sensations of
heaviness, and myonclonic jerks. However, in a poll involving 116
psychologists using meditation, only 3.8% of their patients needed to
terminate as a result of these and other side effects. While transitory
negative side effects are relatively infrequent, Astin et al. (2003) concluded
that it was only prudent to apply such therapies after careful evaluation
of patients and in the context of an appropriate professional relationship
(p. 139).
Stage Model of Meditative Complications
Are there complications for advanced practitioners as well as side
effects for those with more integrated personalities? To answer this one
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needs to view both personality and the expansion of consciousness

through meditative practice in a more extended developmental sequence.
At each progressive stage in development, new complications can arise
while those previous can be subverted.
Based on a condensed version of the traditional Buddhist model of
the path of insight discussed in Chapter 3, Epstein and Lieff (1981)
identified possible psychological complications according to four stages of
meditative development.
Stage 1. Preliminary Practice
In the first stage of mindfulness meditation, beginners observe and
confront their mind, perhaps for the first time. In the process of trying to
train and control the ever-wandering mind, the practitioner is apt to feel
inadequate, frustrated, worthless, overwhelmed, and afraid. Meditators
might question who is in control of their mental states as well as the
validity of their emotional experiences. In the Epstein and Lieff (1981)
study, subjects frequently reported unusual experiences, visual and
auditory aberrations, hallucinations, and unusual somatic experiences
(p. 142). Subjects with sufficient ego development remained comfortable
throughout these experiences, and successfully moved to the next stage of
development. But those without the ego-stability necessary to weather the
storm of the mind were more likely to experience psychological friction
and complication. Epstein and Lieff (1981) stated, On the more primitive
end of the continuum of ego development, there are some whose
precarious defense mechanisms cannot withstand the onslaught of this

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internal experience. Thus psychotic defense mechanisms of denial,

delusional projection, and distortion may manifest (p. 142).

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Stage 2. Access Concentration

The second stage marks the practitioners initial experience of
genuine concentration on the object of meditation. For the first time, they
control what is known in Buddhism as the monkey mind, the result of
which is their experiencing the first successful level of the practice.
Although concentration is not yet refined, practitioners intentionally place
their attention on a single object (for a brief period of time), and
nonjudgmentally observe the arising and falling of thoughts. For the
novice, this stage marks the introduction of relief, inspiration to continue
practice, and increased self-worth.
But, along with these new abilities, there often arises a destructive
ambition to control the results of meditation. When practitioners try too
hard, they can wind up blocking their aims, and experience such
problematic effects as anxiety, agitation, and physical pain in the
shoulders, neck, and back. Some adherents of the Buddhist tradition
diagnose this disorder as Zen sickness, the desire for more control;
although, when done correctly, mindfulness meditation attempts to
counter such effects
Stage 3. Samadhi
In Stage 3, meditators are able to access further levels of absorption
(jhana) or trance. These stages introduce pleasant subjective experiences,
such as feelings of peace, calm, joy, and equanimity; and then progress to
more abstract sensations, which correspond to the formless realm. These
positive results, however, can become the object of attachment and

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clinging, factors which contribute to further suffering. According to

Epstein and Lieff (1981)
Higher states of meditation contain numerous experiences
involving visions of bright lights, joyous and rapturous feelings of
body and mind, tranquility, lucid perceptions, and feelings of love
and devotion. . . . These states exert seductive influences which can
become quite serious according to meditative traditions [and]
attachment to these states marks a major abuse to the meditative
process. It is not until the pride is made the object of meditation
that the individual can pass beyond this stage. (p. 144)

Stage 4. Insight
If the path of mindfulness is developed after concentration has been
significantly strengthened, then further psychological experiences can
occur. Nonjudgmental observation of the moment-to-moment nature of
the mind, which involves noticing the arising and passing of thoughts,
allows for the acquisition of wisdom. By directly experiencing the
transient, essenceless, and ultimately unsatisfactory nature of all things,
meditators awaken in themselves a profound insight into reality. At the
same time, this spontaneous illumination can have negative consequences.
Individuals who are able to discriminate between very subtle moments of
consciousness challenge their previous assumptions and understanding of
duality, which can result in an existential predicament. Epstein and Lieff
(1981) add that
A period characterized by the subjective experience of dissolution
is entered where traditionally solid aspects of the personality begin
to break up, leaving the meditator no solid ground to stand on.
This is traditionally a time of spiritual crises, characterized by a
great terror, the Great Doubt, and as the struggle to allow a
transformation or decathexis of the self. (p. 144)
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Clinical Value of Mindfulness Meditation

Mindfulness Meditation: Adjunct to Psychotherapy
Mindfulness and Short-Term Psychotherapy
Deatherage (1976) studied the effectiveness of mindfulness
meditation as a primary and secondary technique with a variety of
psychiatric patients in short-term therapy. He conceptualized meditation
as a self-treatment regimen with various benefits that included
introducing patients to their own mental processes and preoccupations,
and presenting a method of access and control over these processes, as
well as its high efficiency and cost-effectiveness for the therapist. Studies
by Carpenter (1977) and D. H. Shapiro and Giber (1978) showed that the
efficacy of mindfulness practice arose from its dual function of relaxation
and insight. In this way, mindfulness meditation helped practitioners
cope with stress reactivity by instilling in them a sense of tranquility
(shamatha). This, in turn, led to the establishment of skills in selfobservation, and cognitive reconstruction, and to a more realistic
understanding (vipassana) of present experience.

Mindfulness and Long-Term Psychotherapy

Kutz et al. (1985), in considering the integration of mindfulness
meditation with psychotherapy, hypothesized that the mechanistic
differences between the two techniques allow these two forms of selfobservation to complement one another (p. 1). The authors considered
several factors that made meditation relevant to psychotherapy, beginning
with the perceptual retraining feature that enabled individuals to
distinguish between thoughts and emotions. Through this form of
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detached observation, patients could perceive a mental object and its

concomitant emotion as separate, distinct entities; and with this insight, be
able to witness how their own thoughts gave rise to afflictive emotions,
thus empowering them to minimize the negative psycho-somatic
pathway. Practitioners of mindfulness meditation also cultivated a
greater use of primary process thinking. As Kutz et al. (1985) explained,
in the meditative state, primary process thinking is first
experienced as intensified perceptual awareness. Objects and their
perceptual representations appear more vivid, and there is greater
awareness of their primary qualities, such as form and color. Any
object in this state can be seen more for what it is rather than just
for the function it represents. . . . Thus objects acquire a quality of
firstness. . . . which introduces greater conceptual flexibility, as the
meditator can consider objects and events outside their usual
conditioned secondary context. (p. 4)
This heightened perceptual sensitivity, which is associated with
primary process thinking, has a two fold benefit. Primarily, it brings a
sense of newness and freshness to the patients everyday experiences; but
it is also an aid in therapy, helping patients understand their internal
dynamics. In this way, it can be seen that mindfulness cultivates an
emotional receptivity instead of reactivity. This loosens unconscious
defenses and allows the emergence of repressed material, which can then
be examined by the nonlinear, flexible, and nonjudgmental rules of
primary process thinking.
Kutz et al. (1985) concluded their study by highlighting three
significant advantages to the use of mindfulness meditation in
psychotherapy: First, they felt that mindfulness acted as a daily and
personal form of psychotherapy:

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It is the cognitive stance that makes mindfulness meditation so

suitable as an adjunctive psychotherapeutic tool. The meditator
can be engaged in a psychobiological form of introspection, outside
the psychotherapeutic session. Through meditation, therapy is
transformed into a daily schedule, as it was prescribed in its
heyday. (p. 6)
Second, they maintained that the continued practice of mindfulness
served as a preparatory forum for the weekly therapeutic session. The
multidimensional, primary processed material displayed during
meditation, as well as the capacity of the observing ego to become aware
of its own contents, provide abundant raw material that can be expanded
on in the weekly psychotherapy meetings (p. 6). Third, the authors
stated that psychotherapy and mindfulness were technically compatible
and mutually reinforcing:
Psychotherapy contains the notion that the understanding of ones
pain and the defenses against it can alleviate suffering and promote
psychological growth. As such, it shares with the Buddhist
tradition the goal of liberation through self-exploration. . . . The
inclusion of meditation should be seen within this context. Modern
sciences can provide the expanding knowledge and framework of
biological and behavioral sciences. Meditation traditions,
particularly Buddhism, provide not only the technology of
meditation practice but also the spirit behind the philosophy that
regards any mental construct, including this model, as a mere
explanation and, as such, impermanent and partly illusionary. The
addition of meditative techniques to psychotherapy should not
challenge psychotherapy nor reduce the function of the therapist.
(p. 7)

Mindfulness and Psychoanalysis

Rubin (1991) reported on the clinical integration of mindfulness
meditation and psychoanalysis involving a case study of long term patient
of his who had recently been trained to meditate. After a year with this
patient, Rubin found that
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meditation, the core practice of Buddhism, can enrich

psychoanalytic treatment. Buddhist practice can enhance selfobservational capacities and thus heighten self-awareness; facilitate
access to unconscious material and enhance empathic attainments;
reduce self-recriminative tendencies; facilitate self-demarcation,
increase affect tolerance and integration and reduce depressive
affect; and foster deautomatization of thought and action. (p. 197)
The author concluded that judiciously applied meditation supplemented
and complemented psychoanalysis; and he encouraged the continued
intermixture of these two forms of personal transformation.
In a previous study, Rubin (1985) found that mindfulness enriched
psychoanalytic listening by developing in the analyst what Freud called
an even-hovering attention. In so doing, the practice then benefited the
therapist as well as the client. Lesh (1970) also noted increased empathy
in counselors as a result of meditation, a finding that was validated by
several other studies (Delmonte, 1990b; Dreifuss, 1990; Dubin, 1991; Sweet
& Johnson, 1990). These studies all pointed to the fact that the acumen of
the therapist was greatly enhanced by an ability to be perceptually and
emotionally present to the client and cognitively free from judgment
regarding the issues that arose. According to Rubin (1985), in discussing
the benefits of meditative mental restructuring,
daily life is often pervaded by mindlessness or inattentiveness
and automatically of thought and action. Our typical mode of
perception is to an unrecognized extent, selective, distorted and
outside voluntary control. We often operate on automatic pilot
reacting to a conscious and unconscious blend of fallacious
association, anticipatory fantasies, and habitual fears that make us
unaware of the actual texture of our experience (p. 606)

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Mindfulness-Based Psychotherapies
Mindfulness-Based Cognitive Therapy
An initial study by Teasdale, Segal, & Williams (1995) determined
how mindfulness complemented conventional cognitive approaches to
depression-relapse prevention. Their rationale was based upon the fact
that structured cognitive treatments for depression caused some clients to
experience a relapse after the period of initial implementation. The
authors pointed out the need for the continuation of preventive
psychological approaches, which could be administered to recovered
patients who were in a euthymic mood.
An information-processing analysis of depressive maintenance and
relapse was used to define the requirements for effective prevention and
to propose mechanisms through which cognitive therapy could achieve a
prophylactic effect (Teasdale et al., 1995). The analysis suggested that
similar effects could be achieved through the use of techniques of stressreduction based on attentional control that was taught in mindfulness
meditation. Teasdale et al. (1995) presented an information-processing
analysis of mindfulness and mindlessness, and of their relevance in
preventing depressive relapse. This analysis provided the basis for the
development of Attentional Control Training (ACT), later changed to
Mindfulness-Based Cognitive Therapy (MBCT) that could be used by
recovered depressed patients. This training integrated features of
cognitive therapy and mindfulness training, and was a new approach to
the prevention of relapse.

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Teasdale (1999) further contributed to the research on mindfulness

by enumerating the precise mechanisms that distinguished it from
cognitive therapy. He made a clear distinction between metacognitive
knowledge (knowing that thoughts were not necessarily always accurate)
and metacognitive insight (experiencing thoughts as events in the field of
awareness, rather than as direct readouts on reality). These findings
supported the research of Kabat-Zinn (1982), who found that disidentification was the key feature of mindfulness meditation in symptom
reduction. Teasdale (1999) examined this distinction, and its relevance to
preventing relapse and recurrence in depression, within the Interacting
Cognitive Subsystems theoretical framework. As an alternative to
cognitive therapy with its focus on changing the content of depressionrelated thought, his analysis focused on changing the configuration, or
mode, within which depression-related thoughts and feelings were
processed and experienced.
The facilitation of this metacognitive insight mode, in which
thoughts are experienced simply as events in the mind, can be a useful
clinical strategy. And whereas cognitive models attempt to transform
unhealthy thinking patterns by changing or substituting thought-patterns
themselves, mindfulness meditation alters the way one relates to these
thought-patterns, by viewing them as distinct entities. Depression-relapse
studies such as Teasdales (1988) indicated that depressive moods
reactivated unhealthy thinking and made cognition patterns difficult to
alter, emphasizing the fact that it is was more effective to change ones
relationship to cognitive schemas than it was to change ones thoughts.
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Support for this above hypothesis came from Teasdale et al. (2000)
who evaluated MBCT as a method to help recovered recurrently
depressed patients disengage from dysphoria-activated, depressogenic
thinking. In this study, 145 recovered recurrently depressed patients were
randomized to continue with treatment as usual or, in addition, to receive
MBCT. Relapse/recurrence to major depression was assessed over a 60week study period. Over the following year, for those (77% of treatment
group) with three or more previous episodes of depression, MBCT
treatment significantly reduced relapse from 66% (control group) to 37%
(treatment group). For patients with only two previous episodes, MBCT
did not reduce relapse/ recurrence.
This was statistically significant, given the findings of Keller,
Lavori, Lewis, and Klerman (1983) whose study concluded that 67% of
patients with three or more depressive episodes relapsed, as opposed to
only a 22% relapse probability for depression first timers. The authors
proposed that MBCT was more effective among patients who had
experienced at least three episodes of major depression because it was
designed to reduce the patterns of depressive thinking associated with
dysphoria, a form of thinking exacerbated by repeated episodes of
depression.
Keller et al. (1983) cautioned, however, that MBCT, which was
intended for use upon recovery from depression, was not likely to be as
effective during an acute depressive episode. According to the authors,
during an acute depressive episode, the patients difficulties in
concentration, and the intensity of negative thinking, interfered with their
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ability to acquire the attentional control skills central to the program. The
authors concluded that MBCT held considerable therapeutic promise,
either alone or in combination with other forms of intervention.
Teasdale et al. (2000) found that mindfulness was more effective
with the higher risk group, for which traditional, nonpharmacological
therapy was relatively unsuccessful. According to the authors, MBCT
offered a promising, cost-efficient psychological approach to preventing
relapse/recurrence in recovered recurrently depressed patients with more
than two episodes; precisely the number currently utilized in diagnosing
major depressive disorder. Cost benefits were derived as the result of two
factors: (a) MBCT could be taught in a group educational format, lowering
treatment expenses and conserving the psychologists time; and (b) for
clients in individual therapy, skills and insights could be developed more
rapidly because much of the therapeutic experience would occur outside
the clinical hour.
Mason and Hargreaves (2001) balanced the quantitative data with a
qualitative study on the use of MBCT for depression. This study explored
the participants' accounts of MBCT in the mental-health context. Seven
participants were interviewed in two phases. Interview data from 4
participants were obtained in the weeks following MBCT. Grounded
theory techniques were used to identify several categories that combined
to describe the ways in which mental-health difficulties arose as well as
their experiences of MBCT. Three further participants who continued to
practice MBCT were interviewed in order to further validate, elucidate,
and extend these categories. The study suggested that the preconceptions
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and expectations of therapy were important influences on later

experiences of MBCT.
In the above study by Mason and Hargreaves (2001), significant
areas of therapeutic change and coping skills were identified, including
the development of mindfulness techniques, acceptance of discomfort and
being able to live in the moment. The development of these mindfulness
skills was seen to hold a key role in enabling patients to grow and heal.
Using these skills in everyday life was also seen as important, and several
ways in which this could occur were studied, including the use of
breathing spaces, also known as mini meditations. The study further
emphasized the importance of patients continuing to adhere to the
practice in order to strengthen their therapeutic gains.
Dialectical Behavior Therapy
DBT is a multifaceted treatment approach used with patients
diagnosed with borderline personality disorder. Borderline pathology
represents an arrest in the development of ego, characterized by deficits in
self/other boundaries, affect tolerance, self-efficacy, and reality testing.
Patients diagnosed with this disorder are prone to homicidal and suicidal
ideation and behavior, and episodically fall into acute crisis. A borderline
patients inability to tolerate anger and rejection, the incessant devaluing
of the therapist, and lack of capacity for insight make psychotherapy,
particularly of a dynamic nature, problematic and often short-lived
(Johnson, 1994).
DBT refers to the metaphilosophy influenced by Zen Buddhism
that acknowledges opposing forces in reality, the synthesis of which leads
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to a new reality (Linehan, 1994). The central dialectic of this treatment

concerns the relationship between change and acceptance. Patients are
asked to change those things that are within their control, such as
replacing dysfunctional behaviors, attitudes, and outlooks, and to avoid
environmental triggers (people, places, and things). Simultaneously, they
are encouraged to accept those things that are beyond their control, such
as their traumatic history, character deficits, physical limitation, and/or
current situation. The primary goals of DBT are distinguishing between
what can be changed and what must be accepted, as well as their eventual
reconciliation.
DBT is long-term and intensive in nature. Patients work with an
individual therapist, participate in skill building groups for at least a year,
meet regularly with a psychiatrist if medicated, and are monitored using a
variety of standard progress oriented measures. In addition, DBT
therapists are required to undergo intensive training and meet regularly
in case collaboration. As in traditional cognitive-behavioral therapy
(CBT), the focus of the treatment is on developing control over the coinfluence of thoughts, emotions, and behaviors. However, DBT differs in
that mindfulness meditation is incorporated in order to provide patients
with a more expedient self-observational tool that accelerates learning and
skills development. Linehan (1993a, 1993b) found that mindfulness
practice strengthened three core skills: (a) interpersonal effectiveness, (b)
emotion regulation, and (c) distress tolerance. She maintained that
meditation provided a structured context for self-observation and self-

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understanding that facilitated treatment between therapy sessions and

group activities.
The first controlled trial of DBT involved chronically suicidal
patients with borderline personality disorder (Linehan, Armstrong,
Suarez, Allmon, & Heard, 1991). During the posttreatment follow-up at
one year, patients had significantly fewer parasuicidal acts, required fewer
hospitalizations, and stayed in treatment longer than the treatment-asusual control group. Other DBT studies demonstrated equally significant
improvements with borderline patients actively engaged in substance use
(Linehan et al., 1999), binge eating (Telch, Agras, & Linehan, 2001) and
bulimia (Safer, Telch, & Agras, 2001). Research indicated that DBT was the
most empirically validated and clinically effective treatment for patients
with borderline personality disorder (Bohus et al., 2000; Clarkin, Levy,
Lenzenweger, & Kernberg, 2004; Lazar, 2005; Linehan, Tutek, Heard, &
Armstrong, 1994; Robins & Chapman, 2004).
Early meditation researchers (Bacher, 1981; Engler, 1984; Goleman,
1976; Russell, 1986) suggested that meditation was contraindicated for use
by patients with serious mental illnesses or limited ego development.
This contention conflicted with several recent studies (Bohus et al., 2004;
Linehan, 1991; McQuillan et al., 2005) reporting that a borderline
population appeared to improve on a variety of subjective and behavioral
scales after learning mindfulness skills. The research is as yet unclear
whether or not meditation is useful for patients with severe pathology and
personality disorder, although there are a few examples of the effective
use of mindfulness with more chronically disturbed patients. One study
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that standouts by Bach and Hayes (2002) showed a 50% reduction in

rehospitalization for patients with psychotic symptoms after only four
sessions of a mindfulness-based intervention known as ACT.
A single-case study (Singh, Wahler, Adkins, & Myers, 2003) of a
mildly retarded patient given a simplified mindfulness practice showed
that he experienced decreased levels of aggression and increased selfcontrol, sufficient enough to permit him to live in a residential community
setting. Linehan (1994) pointed out that lower functioning patients were
often unable to practice mindfulness as intensively as was clinically
recommended (Kabat-Zinn, 1990; Segal et al., 2002); although with
adaptations to frequency and duration, it became possible for them to
benefit.
DBT research has lent support to the concept that mindfulness
could be judiciously applied to a wide spectrum of mental illnesses and
need not be relegated to neurotic or higher functioning individuals
(Loizzo, 2000). The perspective of traditional Tibetan and Indian Buddhist
psychiatry and medicine (Clifford, 1984; Loizzo, 2006b) is that meditation
is contraindicated when a patient does not possess the capacity for selfreflection and learning, either due to biological or psychological deficit. In
these cases, Buddhism recommends natural remedies to alter
biochemistry, based on very elaborate systems of Indo-Tibetan and
Aurvedic medicine. There are conflicting reports between Western and
Buddhist sources as to the prerequisites of meditative learning and those
who should be excluded from using the technique.

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Mechanisms of Clinical Effects in Mindfulness

With the advent of MBSR and more recent clinically oriented
hybrids such as MBCT and DBT, several other therapeutic interventions
incorporating mindfulness meditation have been developed, including
Acceptance and Commitment Therapy (ACT) (Hayes, Strosahl, et al.,
1999) and Relapse Prevention (RP) (Marlatt, 1994; Marlatt & Gordon,
1985). But it was difficult for researchers to identify the precise
mechanisms by which these interventions enabled patients to achieve
success, primarily because they were integrative in nature and hindered
the ability to analyze their particular active components (Loizzo &
Blackhall, 1998).
Other concerns were raised by Bishop (2002) who stated that there
was no evidence that the use of MBSR increased the patients ability to
reach a state of mindfulness. According to Bishop, these group
interventions merely produced nonspecific benefits, such as self-efficacy
and social support, or were corollaries of relaxation. Considering the
demands of a meditation program and a daily practice, the author
questioned if success rates were correlated with those preexisting
personality traits of patients that influenced recruitment and compliance.
According to Bishop, it is entirely possible that the efficacy of this
approach has more to do with the kinds of people who gravitate to [this
kind of] program than the [mindfulness] approach itself (p.76).
Baer (2003) responded to some of these concerns providing several
alternative mechanisms that could explain how mindfulness skills led to
symptom reduction and behavioral change. She proposed the following
five factors: (a) exposure, (b) cognitive change, (c) self-management, (d)
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relaxation, and (f) acceptance. In addition to Baers list, Deikman (1971),

J. Miller (1993), and Kelly (1996) provide three other mechanisms of
clinical change including (g) deautomatization, (h) lifting repression, and
(i) existential relief.

Exposure
Exposure refers to the instruction given in mindfulness meditation
to observe thoughts, emotions, and/or sensations nonjudgmentally and
without reacting. In Kabat-Zinns (1982) early work, chronic pain patients
were asked to focus their attention directly on pain sensations as well as
secondary aversive cognitions and emotions. Despite their discomfort,
patients began treating thoughts and emotions in a similar fashion rather
than as directives and experiences to be either followed or avoided. Their
ability to observe mind-body processes in this particular way over time
reduced distress. By allowing and accepting events and experiences to
continually arise, patients developed distress-tolerance and desensitized
their compulsive and automatic reactivity. As Linehan (1993a) noted,
fostering behaviors that neither avoided nor escaped particular reactions,
extinguished the fear response and avoidance behavior previously elicited
by these stimuli. This did not mean that their conditions were cured; but
rather that their ability to live with these conditions without exacerbating
them was increased.
According to Baer (2003)
prolonged exposure to the sensations of chronic pain, in the
absence of catastrophic consequences, might lead to
desensitization, with a reduction over time in the emotional
responses elicited by the pain sensations. Thus the practice of
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mindfulness skills could lead to the ability to experience pain

sensations without excessive emotional reactivity. Even if pain
sensations were not reduced, suffering and distress might be
alleviated. (p. 128)
She maintained that exposure was not a concept that was especially
behavioral since developing tolerance and reducing emotional reactivity
were common skills in all orientations. Baer (2003) noted, however, that
in contrast to clinical strategies that required patients to induce and
initiate symptoms in order to systematically desensitize them,
mindfulness practitioners were asked to simply observe the flow of
consciousness as it naturally arose.

Cognitive Change
Cognitive change refers to the perceptual reorientation that is
achieved through mindfulness meditation. Here the cognitive strategy in
mindfulness does not resemble or correspond to conventional cognitive
therapies, which attempt to reframe distorted thoughts, challenge
irrational beliefs, replace negative schemas with positive affirmations, and
distract attention away from negative thoughts. Mindfulness, on the other
hand, transforms ones orientation towards the entire context of thinking
rather toward any of its specific contents. In this sense, thoughts are
treated as just thoughts, as opposed to their being viewed as reflections of
reality or of truth. As a result, they do not necessitate the level of
emotional and behavioral reactivity to which they would ordinarily have
given rise.
In Nat Hahns (1976) approach to mindfulness practice,
practitioners were asked to view thoughts as clouds passing in the sky of
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their mind, and then to return to observing the breath without following
or attaching themselves to the clouds. In this way, depressogenic or
anxious thought patterns lost their impact and did not become sources of
obsession or anxiety. Therapeutically, this marked a shift away from
individually correcting each thought distortion or belief; and, instead,
addressed the manner in which individuals related to thought processes
in general.

Self-management
Self-management refers to the ability for mindful observation to
provide a space between cognitive-affective stimulus and automatic
behavioral responses, which permit individuals to implement coping
skills and augment healthier interventions. In the present study, this space
was previous discussed in terms of two key processes: deautomatization
(Deikman, 1966; Rubin, 1991) and cognitive-affective uncoupling (KabatZinn, 1982). Epstein (1998) also referred to this process as unintegrating; in
other words, as a process that allowed patients to let go and to find release
from developing and reinforcing habitual cognitive, emotional, and
behavioral patterns that resulted in dissatisfaction and mental anguish.
Kristeller and Hallett (1999) found that women with binge eating
disorders were able to improve recognition of binge urges as well as
subtle satiety cues, affording them an opportunity to make healthier
eating choices and to practice self-care strategies. Marlatt and Gordon
(1985) made the identical observation with alcoholicsand by logical
inference, patients struggling with substance abuse. According to Marlatt
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and Gordon, mindfulness slowed automatic reactive patterns and allowed

patients to maintain the necessary awareness to intervene with relapse
prevention strategies before the urge to drink became overpowering.
Linehens (1993b) observation of borderline populations also found that
increased self-awareness and behavioral observation permitted the
introduction of corrective responses, such as self-soothing tactics or an
emergency phone call to their case worker immediately preceding the
moment when emotions became unmanageable, triggering selfdestructive behavior.

Relaxation
Relaxation refers to the capacity for all meditation regimens to
lessen arousal through initiating parasympathetic activity (see Chapter 4
of the present study). Though mindfulness meditation is not exclusively
designed to produce calm and relaxation, some of its basic practices (i.e.,
bare attention, awareness of the breath) have the ability to override stress
reactivity, thereby decreasing the impact of medical illness and disorders.
Though Bishop (2002) assumed that the benefits of mindfulness were
correlated with relaxation, it is unlikely that this was the only reason that
it worked.

Acceptance
Acceptance refers to the ability to accept both pleasant and
unpleasant states of being, the importance of which is frequently
underestimated in current treatment approaches. Most conventional
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therapies aim at change, correction, removal, or suppression of symptoms.

On the other hand, according to Baer (2003), all of the mindfulness-based
treatment programs that she reviewed included acceptance of pain,
thoughts, feelings, urges, or other bodily, cognitive, emotional
phenomena, without trying to change, escape or avoid them (p. 130). In
order to highlight the distinction in approach, she used the example of
patients with panic disorder. Such patients, in an attempt to avoid future
panic attacks, often engage in maladaptive behaviors, such as drug or
alcohol abuse, social isolation, and bodily hyper vigilance. Barlow (2001)
noted that medication and CBT were the most desired and effective
interventions for patients with this disorder. The aim of these two
interventions was to chemically alter arousal pathways and to
therapeutically mitigate the effects of panic-producing thoughts.
The mindfulness method takes the opposite approach, fostering
acceptance and receptivity towards panic attacks, which, though
unpleasant, are time limited and not dangerous. By learning through
mindfulness to continuously and directly face the consequences of attacks,
patients are able to lessen their anxiety about them. Furthermore, harmful
behaviors designed to avoid the experience of panic are decreased or
abandoned. The emphasis of mindfulness on acceptance corresponds to
the First Noble Truth within Buddhist metapsychology, that life is
difficult, and by our very nature human beings are bound to experience
sickness, pain, old age, and death. According to Nat Hahn (1976), from
this perspective, ones afflictions become opportunities to disarm limiting
emotions, such as fear and aversion, and accept a new way of being, as
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well as embracing a kind of bare attention which sees things as they really
are, as if for the first time (Harvey, 2000).

Deautomatization
Deikman (1966a) coined the term deautomatization, which he
defined as an increased flexibility of perceptual and emotional responses
to the environment, resulting in the manifestation of previously
imperceptible aspects of reality. He went on to state that mindfulness
meditation was an attentional strategy that elicited such a reaction,
serving as a regression to the perceptual and cognitive state of a child.
This description is consistent with that of Zen Master Suzuki (1994), who
suggested an optimal state known as beginners mind, where freedom was
achieved through moment-to-moment receptivity toward reality,
uncontaminated by previously conditioned perceptions. Deikman (1982)
characterized this experience of beginners mind as consisting of five
principles: intense realness and freshness, unusual sensations, unity,
ineffability, and trans-sensate experiences. He defined trans-sensate
experience as a state that went beyond customary pathways, ideas, and
memories, the result of a new perceptual ability that responded to
dimensions of the stimulus array that had been formerly disregarded or
blocked from consciousness.
In a later study, Deikman (1971) used the term deautomatization to
describe the cognitive changes resulting from mindfulness meditation,
brought about by the reinvestment of ones actions and precepts. He
maintained that mindfulness meditation caused a shift toward a mode of
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cognitive organization that preceded the analytic, abstract, and intellectual

mode. He described this perceptual mode as being more vivid, sensuous,
syncretic, animated, and dedifferentiated, with respect to the self/other
dyad between objects and sense modalities. This process was also
identified by Rubin (1991) who stated that meditation fostered the
deautomatization of thought and action. Kabat-Zinn (1982, 1990) also
stated that Buddhist practices such as mindfulness, bare attention, and
zazen supplanted ones conditioned reactive, perceptual, and affective
response patterns, resulting in a more direct moment-to-moment
encounter with internal functioning and external activities.

Lifting Repression
J. Miller (1993) focused on the lifting of repressed material and the
unveiling of traumatic events during mindfulness meditation, describing
three case reports in which patients uncovered traumatic memories and
how mindfulness facilitated the process. According to J. Miller (1993), the
nature and degree of the transformative experience depended to a great
extent on the level of self-efficacy experience by the participant. However,
all 3 individuals whom he studied saw their experiences as essential to
their continued growth and healing; and none had any regrets about the
unveiling that they underwent during their practice. Indeed, in spite of
the intensity of their emotional suffering, all 3 chose to continue to
practice meditation.
In addition, J. Miller (1993) maintained that mindfulness meditation
not only facilitated the emergence of unresolved material, but it also
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helped practitioners to develop a detachment or disinvestment towards

these events:
Often repressed material surfaces with its original intensity. The
instructions are to maintain a nonjudgmental awareness of this
material, and observe the process of mind rather than the specific
content. As mindfulness strengthens the meditator is able to face
increasing more difficult material with calmness and equanimity.
Similar to what often happens in psychotherapy [or in behavioral
techniques like desensitization] previously repressed material
continues to arise as the meditator becomes more skillful at
working with it. (p. 171)
The above case reports led J. Miller (1993) to conclude that mindfulness
meditation could be potentially helpful as an adjunct to psychotherapy.
He also discussed various integrative models, including self-oriented
psychotherapy, which combined a regular mindfulness practice with less
frequent psychotherapy sessions:
This would reduce the cost of psychotherapy and very likely
facilitate progress as unconscious material is unveiled in
meditation. Of course, this model would not be appropriate for all
individuals, especially for those who are at high risk for significant
psychological distress through meditation practice. (p. 178)

Existential Relief
Kelly (1996) reported on the benefits of meditative techniques in
psychotherapy for patients who felt that their lives lacked meaning. These
clients worked hard to gain material comforts and other indications of
success; but instead of being happy and fulfilled, found themselves feeling
disillusioned, empty, and depressed. As a direct correlate, Kelly noted
that the three most commonly prescribed medications in America were
anticular drugs, hypertensive drugs, and antidepressants. Despite the
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trend of modern Western therapy to ignore spiritual concerns for those

that they consider pragmatic, Kelly pointed out that such distinctions did
not exist between the two domains. He maintained that the lack of
fulfillment in peoples lives could not be separated from the myriad
afflictions that they were addressing in therapy. At the same time, those in
the helping professionals were usually ill-prepared or hesitant to deal
with this lack of fulfillment. According to Kelly (1996),
meditative approaches represent one route that is available to
therapists for working on a variety of different levels with clients,
ranging from the very practical, day to day concerns of stress and
healthful living to the broader existential issues of purpose and
meaning that might be considered to be part of spiritual well-being.
(p. 41)
Kelly (1996) noticed a growing trend in the patient population for
treatments that considered the spiritual dimensions of life. He cited one
study (Eisenberg et al., 1993) that reported that in 1992, one third of
patients sought unconventional treatments. Eisenberg et al. (1993) also
found that approximately one in four Americans used an unconventional
treatment in conjunction with their physicians prescriptions. Among
these unconventional therapies were meditation, prayer, homeopathy,
mental imagery, yoga, and energy healing. This demand for alternative
treatments that addressed issues ignored until recently provoked the
mental health industry to more seriously consider approaches such as
meditation. Lukoff et al. (1993) pointed out that at gatherings of the
American Psychiatric Association and at other professional meetings,
there was a growing number of presentations, workshops, and research

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focusing on transpersonal, spiritual, and existential aspects of clinical

treatment.
Kellys (1996) study focused on the potential effectiveness of,
meditation in psychotherapy, concluding that
the shifting paradigms of our culture and of the healing profession
are creating new potentials for ancient, time-tested philosophies
and practices to be blended with the relatively new techniques that
psychotherapy has made available, yielding a more holistic and
comprehensive perspective. (p. 46).
Loizzo (2000) further supported this, stating that the recent
National Institutes of Health (NIH) initiative to fund mind/body medical
centers reflects the consensus that self-regulation techniques such as
meditation are of proven value for many conditions and are vital to the
future of medicine (p. 153).
In his final discussion on the potential effects of mindfulness
Bishop (2002) determined that there were more benefits than he had
originally anticipated. He pointed out several unique qualities that
mindfulness cultivated in patients, including a shift in perspective from
automatically accepting the validity of thoughts and emotions to
momentarily suspending judgment. He also noted a sense of nonstriving,
which he described as a surrender or acknowledgement of the moment.
No longer were patients trying to fight, change, or avoid the situation, or
even to attempt to achieve another, more preferred experience. In this
way, there was an emphasis on the immediacy of the current situation,
rather than on the past or future. As the author summarized
The voluntary deployment of attention, in combination with these
attitudes, is thought to result in a heightened state of awareness in
which one is conscious of a particular situation and ones cognitive,
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emotional and somatic experience in a way that fosters a greater

sense of equanimity. Thus, in addition to attentional regulation
skills, mindfulness can be conceptualized in terms of a core set of
attitudes and a general approach-orientation to experience. (p. 75)
Meta-Analyses and Methodological Issues
A number of literature reviews and meta-analyses (Baer 2003;
Banadonna, 2003; Bishop 2002; Gremer et al., 2005; Grossman et al., 2004;
Loizzo, 2000) have recently been conducted to review the efficacy of
mindfulness-based interventions. By cross-referencing some of these
sources it becomes possible to extract consistent findings, compare areas
of disagreement, and synthesize recommendations for future research.
Points of Comparison Between Meta-Analyses
Inclusion Criteria
Grossman et al. (2004), Baer (2003), and Bishop (2002) provided
meta-analyses using standard methodological procedures, which they
presented in reputed peer review journals. Each report indicated that
there were numerous studies of mindfulness, yet few met the criteria for
acceptable quality and relevance, and could not included in their
evaluations. Most recently, Grossman et al. (2004) found 64 empirical
studies on MBSR, but retained only 20 for their meta-analysis, including
10 that were well controlled, with the remaining studies relying on an
intra group pre/post design. Their reasons cited for exclusion were (a)
insufficient information provided as to the nature of the intervention; (b)
poor quantitative health evaluation; (c) inadequate statistical analysis,
such as effect size; (d) mindfulness not being the central component of the
intervention; or, (e) the setting for the intervention deviating too widely
from the original health-related context of MBSR.
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Baers (2003) meta-analysis reviewed 21 reports on MBSR and

MBCT, including 11 with control groups. Baer excluded studies on DBT,
ACT, and RR because they failed to isolate mindfulness from the overall
program effect. Bishop (2002) found 13 reports on MBSR and MBCT
worthy of review at the time of his research, but only 4 were controlled
clinical trials. All three meta-analyses cited methodological improvement
as their primary recommendation for future mindfulness research with
Bishop (2002) being far more critical in his discussion.
Target Populations
While many of the studies that were compiled and reviewed
overlapped, they nevertheless revealed an impressive diversity of target
populations and disorders to which mindfulness was applied (Baer, 2003;
Bishop 2002; Grossman et al., 2004). Populations were categorized into
four types: medical, psychiatric, mixed (medical and psychiatric), and
nonclinical (i.e., students, healthcare providers, inmates, and general
volunteers). The variety of dependent measures or disorders targeted
according to the population included (a) medical illnesses: chronic pain,
fibromyalgia, psoriasis, cancer, multiple sclerosis, hypertension, coronary
artery disease, and epilepsy; (b) psychiatric disorders: anxiety, eating
disorder, depressive disorder; and, (c) clinical issues: stress level, anger
level, self-concept, self-esteem, ego-defense mechanisms, religiosity, locus
of control, and general wellness. The following discussion presents
general findings and conclusions drawn from these three meta-analyses.

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Mean Effect Size

Grossman et al. (2004) found MBSR to be a useful intervention for a
broad range of chronic disorders and problems, indicating that
the consistent and relatively strong level of effect sizes across very
different types of sample indicates that mindfulness training might
enhance general features of coping with distress and disability in
everyday life, as well as under more extraordinary conditions of
serious disorder or stress. (p. 39)
Specifically, they reported a mean effect size of almost 0.49
pertaining to six studies involving active control and a mean effect of 0.58
for four other studies employing waitlist control. While the authors
cautioned readers not to generalize these findings, they responded to
Bishops (2002) earlier concerns by controlling for the nonspecific effects of
the mindfulness intervention program.
Baer (2003) found mindfulness interventions to demonstrate
statistically significant reductions in symptoms of pain, anxiety,
depression, binge eating, and stress levels. After tallying the
posttreatment scores for 15 independent studies and calculating the mean
effect size, Baer found an overall mean of 0.74 (SD = 0.39). When each of
these 15 effect sizes were weighted by sample size, the overall
posttreatment effect size of mindfulness studies reviewed was 0.59, a
comparable finding to Grossman et al.s (2004) waitlist control effect size.
Thus, on the average, the literature review here suggests that
mindfulness-based interventions have yielded at least medium-sized
effects, with some effect sizes falling within the large range. Many of the
effect sizes calculated for these studies are probably conservative. . . .
(Baer 2003, p. 135)
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Methodological Weaknesses
Grossman et al. (2004) identified several methodological
weaknesses in their review. The lack of follow-up data provided by most
studies restricted analysis to more or less immediate effects. While there
was research on the long-term effects of mindfulness on chronic pain
(Kabat-Zinn et al., 1987; Randolph, Caldera, Tacone, & Gareak, 1999),
anxiety (J. Miller et al., 1995), psoriasis (Kabat-Zinn, 1998), depressive
relapse (Segal et al., 2002; Teasdale et al., 2000) and stress and mood in
cancer patients (Carlson, Ursuliak, et al., 2001) the authors felt that much
additional follow-up research is needed to confirm these and other
benefits. Grossman et al. (2004) listed other major deficiencies, such as
insufficient consideration or information was typically given about
participant drop-out rate, other concurrent interventions during the
mindfulness training period, therapist adherence to intervention
program, evaluation of therapist training and competence,
descriptions of interventions, adequate statistical power to calculate
intervention effects, or the clinical relevance of results.
Additionally, the construct of mindfulness itself, although central
to all interventions, was neither operationalized nor evaluated for
change in the study. (p. 40)
In her review, Baer (2003) also summarized several methodological
weaknesses, beginning with the lack of active control groups. Most
studies on mindfulness used an intra-group, pre/post design that did not
control for the passage of time, or demand characteristics, placebo effects,
or comparison with other interventions. Many studies used too small a
sample size. Baer recommended that future research should include at
least 33 participants to statistically achieve a medium-to-large treatment
effect.
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She also found little-to-no control for integrity and consistency in

the delivery of the intervention. Only one report (Teasdale et al., 2000)
described methods for monitoring how instructors train in and deliver the
MBCT protocol and interventions. Mindfulness programs require their
instructors to undergo extensive training and supervision; the omission of
these details and methods of accountability makes it difficult to isolate
quality of the instruction from the overall effect.
Finally, according to Baer, clinical significance is typically
undetermined. While statistically an intra group difference can indicate a
post treatment effect, it is important for symptom reductions to be
compared with normal ranges in the general population on relevant
dependent variables.
Bishop (2002) provided the most critical appraisal of the research
methods used in several of the mindfulness studies discussed by
Grossman et al. (2004) and Baer (2003). For example, Shapiro et al. (1998)
examined the effects of MBSR on levels of stress and dysphoria in a
medical student population and determined it to be effective in lowering
symptoms after an 8-week intervention. While matched randomization
and replication of the study with a control group eliminated confounding
variables and provided additional data for intervention-efficacy, Bishop
pointed out the limitations of using an inactive control group. Since
nonspecific factors such as therapists attention, social support and
positive expectancy can improve outcome it is difficult to attribute the
changes to the specifics of MBSR (p. 72).

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Bishop (2002) referred to Speca et al. (2000) whose study achieved

reductions of 65% of mood disturbance and 35% of stress symptoms in a
mixed-cancer patient population following MBSR. According to Bishop,
it is not possible to rule out social desirability effects that may have been
operative in patients reports of mood and stress changes or their reports
of treatment compliance (p. 72).
Finally, Bishop stated that Teasdale et al. (2000), in their study of
MBCT for depressive relapse prevention, offered the most rigorous study
to date. This study included randomization, active control group,
sufficient sample size and 6-month follow up. Those interested in
producing a mindfulness study in the future are advised to follow these
methodological provisions closely. However, Bishop asserted that the
Teasdale et al. (2000) study failed to isolate the effect of mindfulness
meditation from cognitive therapy, and cautioned against making strong
statements regarding the effectiveness of meditation per se.
Defending the criticism that most studies involving mindfulness
failed to use rigorous control designs, Lazar (2005) maintained that there
was
difficulty in creating a control intervention that adequately matches
the core elements of mindfulness practice. For example, to make a
controlled study of MBSR, we would require an 8-week group
format, with 40 minutes of daily homework that is compelling
enough to get participants to comply, but has no therapeutic value.
(p. 222)
Potential Benefits
There is a general consensus in the literature regarding the efficacy
of mindfulness-based interventions; and future researchers are
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encouraged to continue, although with more stringent methodologies.

Grossman et al. (2004) stated that
the literature seems to slant toward support for basic hypotheses
concerning the effects of mindfulness on mental and physical wellbeing. Mindfulness training may be an intervention with potential
for helping many to learn to deal with chronic disease and stress.
(p. 40)
Similarly, Bishop (2002) concluded his study by stating that MBSR
promised to offer a potentially effective treatment option that could help
some patients to manage their stress and mood symptoms in the face of
their illness. Baer (2003) agreed with Bishop and summarized her review
findings by stating that
in spite of the methodological flaws, the current literature suggests
that mindfulness-based interventions may help alleviate a variety
of mental health problems and improve psychological functioning.
These studies also suggest that many patients who enroll in
mindfulness-based programs will complete them, in spite of high
demands for homework practice, and that a substantial subset will
continue to practice mindfulness skills long after the treatment
program has ended. (p. 139)
Baer (2003) also reviewed criteria set out by the Division 12 Task
Force on Promotion and Dissemination of Psychological Procedures. In
her estimation MBSR and MBCT both met the criteria for designation as
probably efficacious because these interventions proved to be more effective
than a waitlist control group or another treatment in two or more clinical
trials. With careful attention paid to methodological issues in future
research, it may not be long before mindfulness-based interventions will
be seen as having a greater capacity to help people than the approaches
currently used in todays field. What seems clear for now is that while
researchers and clinicians are aware of the health benefits of mindfulness
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meditation, more independent, full-scale clinical trials with significant

results are required in order to shape the policy and dissemination of this
technique. With the pervasive use of mindfulness imminent, serious
questions arise regarding how health care provides should preserve the
integrity of, train in, adequately deliver and ethically be supervised in this
technique.

Summary
The chapter explored the differences between Buddhist and
conventional psychology, with particular emphasis on the effects that
each, mindfulness meditation and psychotherapy, have on ego structure
and development. It was shown that historically the literature endorsed a
sequential model in which psychotherapy precedes meditation practice,
although currently Buddhist-oriented clinicians have made a strong
argument for a simulations approach to treatment. The research reviewed
contraindications and adverse effects of mindfulness practice and then
complemented this with recent clinical outcome studies supporting its
efficacy for a wide range of mental health issues. The research findings of
mindfulness from the various Buddhist, scientific and clinical perspectives
reviewed to this point will now be further integrated and synthesized.

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CHAPTER 7: INTEGRATION AND SYNTHESIS

The above review has focused on three areas of research in the literature:
First, the theory, application, and effects of mindfulness meditation as
presented in its traditional context in Buddhist psychology; second, the
extensive empirical research conducted over the last 50 years, including
studies that addressed the physiological, neurological, and psychological
effects of mindfulness meditation; and third, clinical studies and evidence
regarding the efficacy of mindfulness meditation as a treatment
intervention for a wide variety of medical and mental heath issues. This
chapter integrates and synthesizes findings regarding mindfulness
meditation in order to provide a coherent perspective of its effects and
benefits.
The Central Role of Disidentification
In reviewing the research several causal mechanisms of
mindfulness were seen as cornerstones of clinical change and healing, the
most crucial being the process of disidentification. Descriptions and
definitions regarding this process have differed greatly. Buddhist sources
used stabilized meditative analysis to disidentify from the erroneous
attachment and reification of self. Western applications of mindfulness
typically did not extend to its advanced stages of analysis of the
observer; rather they focused on disidentifying from problematic
thoughts, emotions and behaviors. As an example, Kabat-Zinn et al. (1987)
found that mindfulness meditation
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evokes a new pattern of perceiving based on intentionally paying

attention in a moment-to-moment mode. It is thus potentially
applicable to a wide range of human activities and experiences.
Mindfulness meditation can be thought of as a generalized
reference-frame shift from partial awareness (an automatic pilot
mode of functioning) to moment-to-moment awareness with a
nonjudgmental, witnessing quality. . . . There are strong theoretical
and practical reasons which suggest that a learned and intentional
use of moment-to-moment awareness can have a profound effect
on pain perception, the experience of suffering, and on stress
reactivity. (p. 171)
Deikman (1982) called this process deautomatization, and defined it
as the undoing of the automatic processes that control perception and
cognition (p. 137). Alternative terms proposed in the West for this
process included cognitive distancing, deliteralization (Hayes, Strosahl, et al.,
1999), decentered perspective, metacognitive awareness (Teasdale, 1999;
Teasdale et al., 1995), unintegration (Epstein, 1998), manual-override (Loizzo,
2004), and cognitive-affective uncoupling (Kabat-Zinn, 1982). What follows
is an integration of findings from the literature based on the notion of
disidentification.
Disidentification in Buddhist Meditation
The aim of Buddhist mindfulness meditation is to foster the ability
to disengage from habitual reactive patterns of thinking and feeling, and
ultimately to disidentify from notions of a reified self rooted within those
patterns (Gyatso, 2000). Once disidentified in this way, the individual is
able to tolerate the physical and mental difficulties that occur in life, rather
than react with attachment and aversion against them. Loizzo (2004,
2006b) determined that conscious self-regulation and cognitive-affective-

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behavioral learning are the active agents associated with the process of
disidentification that lay at the heart of the Four Noble Truths.
The Buddhist Four Noble Truth medical model traces the causes of
human suffering to the unconscious impulses of fear-based attachment
and defensive-hostility rooted in reified-self habit (Loizzo, 1999). Recent
empirical studies suggested that toxic emotions (Goleman, 2003a, 2003b)
including anger (Harmon-Jones, 2004; Harmon-Jones, & Allen, 1998;
Ornish et al., 1990), hostility (Williams, 1989), and self-involvement
(Graham et al., 1989; Scherwitz et al., 1986) had a greater correlation to
mortality than coronary artery disease, high cholesterol, high blood
pressure, smoking, and diet. These studies supported the ancient
Buddhist mind science that underscores the significant role played by an
individuals outlooks, attitudes, and behavior on his or her health. In
contrast to the current Western allopathic and bio-medical models of
disease, based on 19th-century Cartesian dualism, Buddhist psychology is
based on a nondual, mind/body paradigm, which utilizes the power of
the mind to affect the brain and vice versa. This result is a new emphasis
on the innate potential of individuals to promote their own health and
healing.
The Buddhist therapeutic curriculum consists of three higher
trainings (adhisiksya): 1) behavioral discipline, 2) attentional-control, and 3)
experiential insight. Each of these works in tandem to reciprocally inhibit
the destructive forces of the three corresponding impulses, of attachment,
aversion, and misknowledge. Loizzo (2004) recommends that the
Buddhist curriculum of the three higher training not be conceived of
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linearly, as if one phase of training eliminates its corresponding types of

defilements before progressing to the next phase of training. Rather the
trainings are different methods that correspond to the increasingly
delicate dimensions consciousness along a continuum, and should be
viewed holistically or cyclically.
Depending on ones state of consciousness, one can attend to
defilements on the external level, internal level or most subtle level. Over
a period of time, one organically vacillates from behavioral modification
to mental/cognitive reframing to reprogramming the unconscious
conditioning, and back again. In this way, the three higher trainings work
cyclically in support of each other.
For example, corrective lifestyle and behavior changes afford
individuals greater attentional control and concentration. Classical
Buddhist behavior modification, detailed in the Monastic Code of
Discipline (Skt Pratimoksha; Pali Patimokkha:) found in the Sutta-vibhanga
(Stv) of the Vinaya-pitaka (Vp), begins with five laymans vows consisting
of abstaining from killing, stealing, lying, sexual misconduct and the
taking of intoxicants. Such behavioral adjustments consequently lead to a
still and peaceful mind and provide the prerequisite mental stabilization
to analyze and subvert unconscious self-reification habits. Reciprocally,
as unconscious tendencies are extinguished and selflessness (anatman)
becomes actualized, ones behavior naturally changes in a positive
learning feedback-loop. When individuals begin to see themselves and
reality more realistically, their mental state becomes more joyful, content,

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and tranquil and their behaviors consequently are altruistic and generous
(De Silva 2000; U Pandita, 1991).
As Goleman (1976) indicates the three higher trainings (adhisiksya)
correct unrealistic behaviors, attitudes and outlooks by introducing and
systematically reinforcing their opposite, more healthy correlates in a
process known as reciprocal inhibition. This corrective learning takes place
on three levels: conceptually through education, reflectively through
discussion and contemplation, and experientially through meditation and
rehearsal (sadhana) (Loizzo, 2004).
Mindfulness meditation is thus a multilevel, cognitive-affectivebehavioral, self-regulatory intervention. It can be used to reprogram
conditioned and instinctual reactive patterns by introducing new modes
of responsiveness based on refined awareness and acceptance. The study
showed that mindful awareness and analytic insight can enable
individuals to learn how to perceive the impermanent, relative, and
dissatisfying nature of attachment to self and phenomena, and thus align
themselves with, rather than against, the ebb and flow of reality (Loizzo,
2000, 2006b; Thurman, 1991).
In current Western terminology, the three higher trainings are aimed
at lifelong learning, preventive health education, and sustainable lifestyle
changes, rather than short-term, disease-specific, mechanistic
interventions. A body of literature (Gould et al., 1995; Ornish et al., 1990,
1998) demonstrated that a comprehensive lifestyle change based on an
Asian mind/body approach could not only arrest the development of
coronary artery disease but actually reverse it. These authors indicated
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that in some cases, medications and the latest surgical interventions were
only able to temporarily maintain the progression of disease. Selfless
attitudes, positive emotions and the capacity to disidentify from thoughts
and emotions were thus seen as essential features of recovery and health
promotion.

Disidentification in Mind/Body Medicine

Studies in mind/body medicine found that mindfulness meditation
elicited the relaxation response, counteracting autonomic fight-flight
patterns, and decreasing stress-exacerbated medical symptoms (Benson,
1975, 1992). According to Teasdale et al. (1995), mindfulness led to
increased physical well-being by enabling individuals to transform their
relationship to medical illness; and from this disidentified perspective,
they could learn how to reprogram their affective response patterns and
be able to approach situations with objective awareness. Thus, a given
situation or context was freed from seemingly inherent, negatively
perceived values, resulting in decreased emotional reactivity (Bishop,
2002).
Kabat-Zinns (1982, 1990) research also reported on the process of
disidentifying by attributing to mindfulness meditation the capacity to
disrupt the fight-flight reactions in anxiety-provoking situations, allowing
for effective responses rather than enactments involving anger, fear, or
panic. Other researchers (Baer, 2003; Breslin, Zack, & McMain, 2002;
Loizzo, 2004), similarly showed that mindfulness meditation could help
individuals by offering a variety of healthy and appropriate coping
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strategies based on disidentification with thoughts, emotions and

behaviors. The results of these so-called shifts in frame of reference: (a)
enabled practitioners to sustain the attention required for demanding
tasks, (b) helped them to retain the cognitive ability for learning and
problem solving, (c) taught them how to communicate and empathize
with others, and (d) gave them an increased sense of self-efficacy and
autonomy. Although it was seen that most meditation practices focused
on eliciting a relaxation response, mindfulness meditation sought to
decrease sympathetic activity in order that individuals might establish an
ideal, internal environment for cognitive-affective learning and behavioral
change (Loizzo, 2006b).
Studies indicated that mindfulness meditation was able to interrupt
cycles of negative internal experiences, such as anticipatory anxiety of
future events, or depressive rumination of past events. This was based on
the idea that through this practice and resulting disidentification,
individuals could regard their beliefs as habits of thinking, feeling, and
perceiving (Tart, 2003) rather than as objective realities. Mindfulness
meditation thus enabled individuals to perceive that it was their beliefs
that determined the manner in which they observed and interacted with
their environment, and they could observe the potential consequences. As
a result, habitual and destructive ways of reacting were replaced with
intentional, adaptive, and constructive ways of responding (Breslin et al.,
2002; Hayes, 2002a, 2004), thereby increasing their coping skills.

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Disidentification in Neuroscience
Research from the field of cognitive neuroscience indicated that
mindfulness fostered disidentification by blocking alpha activity, and
priming the brain to be acutely receptive to sensory input (Lo et al., 2003).
Not only was a state of relaxed alertness brought about, but as the
Davidson et al. (2003) study indicated, mindfulness also produced greater
levels of left-sided activation of anterior regions in the brain, regions
associated with decreased anxiety and increased positive affect. A high
correlation between left-side brain activity and increased immune
function was found, suggesting that positive emotion was one of the
mechanisms underlying stress-hardiness and the improvement of
immunity (Davidson & Irwin, 1999). This finding was consistent with that
of neuroplasticity research, that the creation of an enriched (stimulating
and pleasurable) environment promoted neural repair, growth, and
change (Rosenzweig & Bennett, 1996; Swaab, 1991). It was thus seen how
significant were the implications of a feedback loop in which brain matter
and function were altered through intention and positive emotion, and
reinforced through meditative training, both of which are still novel and
controversial concepts in the field of meditation research.

Disidentification in Psychotherapy
In the review of the psychology literature mindfulness was found
to foster disidentification in terms of a cognitive-affective process of
interoceptive exposure, desensitization, and extinction (Hayes, 2002a,
2002b, 2004). During mindfulness training, participants exposed to a series
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of threatening or near-intolerable stimuli were able to develop a sustained

and nonjudgmental awareness of these uncomfortable psychological
experiences which included thoughts, affects, and physical sensations
(Baer, 2003; Hayes & Wilson, 2003). The prolonged observation of
uncomfortable experiences then further induced participants to lessen
their emotional avoidance of previously unacceptable stimuli. This ability
was based on the concept of desensitization proposed in cognitivebehavioral psychology (Barlow, 2001; Hayes, 1987). It was thus seen that
mindfulness enabled individuals to re-parent themselves, to self-regulate
affect, to learn positive responses based on present-moment awareness
and acceptance, and to override conditioned reactions based on
avoidance, fear, and hostility (Breslin et al., 2002; Hayes, 1994).
In addition, mind/body therapies and mindfulness-based
educational programs have consistently been found to be advantageous to
Western patients, whether as an adjunct to allopathic treatments or in
place of such conventional interventions. An added incentive that was
discussed was that meditation instruction and supervision could be
delivered at a fraction of the emotional and financial cost of conventional
medicine and invasive surgeries (Goleman & Gurin, 1993; Kabat-Zinn,
1990).
Buddhism and Psychology Reconsidered
The aim of mindfulness meditation is to provide insight into the
impermanent (anicca), insubstantial (anatman), and dissatisfying (dukkha)
nature of phenomena. It can lead to the deregulation of reinforced
negative habit patterns and unhealthy affects. Deeply rooted impulses
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(kleshas), also conceptualized as libidinal drives (fear-based attachment,

hostility, defensive alienation) and compulsive behaviors (karma), are
brought under conscious observation and disidentified from through
penetrative self-analysis.
The Buddhist therapeutic curriculum of the three higher trainings
(adhishiksha) cultivates disciplinary intentions (sila) and empathic behavior
to counteract clinging, and cultivates meditative equilibrium (samadhi) and
tolerance to counteract anger and other adversive mental states. The
curriculum also cultivates insight (prajna) to counteract alienation and selfpreoccupation by developing a realistic outlook that perceives our
universal interconnectivity.
In his groundbreaking report, Loizzo (2000) stated compellingly
that the extensive synthesis of various therapeutic paradigms made the
Buddhist meditative system the oldest and most comprehensive
integrative psychology in world history. As discussed in Chapter 3, these
three major paradigms include: the Individual Vehicle tradition
(Hinayana), the Social Vehicle tradition (Mahayana), and the Adamantine
Vehicle tradition (Vajrayana). Loizzo (2004) pointed out that the
integrative nature and sophistication of Buddhist meditative practice
explains why it has been compared to so many divergent
psychotherapeutic techniques (Benson, 1976; Epstein, 1995; Kabat-Zinn,
1982; Linehan, 1993a, 1993b; Mikulas, 1978, 1981). Loizzo (2000) provided

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the following method of synthesis between traditional Buddhist, and

conventional Western, psychotherapies.
In the Individual Vehicle tradition, prevalent in Southeast Asia,
vipassana is practiced with an attitude of renunciation and is akin to
cognitive behavioral therapies. Practitioners view behavior as ingrained
by habitual action (karma) and reinforced by conditioning, yet modifiable
by learning. Such a view is also akin to classic dynamic psychotherapy
because it recognizes that cognitive and emotional defenses, deeply rooted
in evolutionary egocentric instincts, hinder the growth process.
In the Social Vehicle tradition, prevalent in East Asia, vipassana is
practiced with a nondual attitude of universal responsibility (bodhicitta). It
is similar to an object-relations approach since it emphasizes social
connections, reinforces healthy emotions, and locates development within
a naturally constructive social field.
In the Adamantine Vehicle tradition, prevalent in Tibet, vipassana is
practiced with an impassioned and creative attitude. Similar to Jungian
and Reichian therapies, such meditation involves meditatively projecting
and internalizing idealized self-images based on visualization archetypes
(yidam). In its highest stages, it uses sexual arousal and euphoria to
disarm behavioral defenses and to enhance mind/body openness. Here
the relationship with, and introject of, the spiritual teacher (guru yoga)
plays a central role, as positive transference with a highly trained adept is
conjoined with self-analysis (Loizzo 2000).
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In the process of acquiring meditative skill, meditators reprogram

basic patterns of perception, cognition and behavior. As this
reprogramming takes root they undergo a fundamental transformation of
the brain, nervous system, and personality (Loizzo, 2006b). The net effect
of mindfulness and analytic insight meditations are the deconditioning of
habitual response patterns, particularly the root cause, the defensive selfhabit, which, when they are once dissolved, free the individual to
experience boundless joy (sukkha), compassion (karuna) and skillful craft
(upaya) in teaching others how to free themselves.
Current empirical research has shown that, as an integrative
technique, mindfulness meditation has the potential to greatly
complement cognitive neuroscience, mind/body medicine, and
psychotherapy by addressing aspects often neglected by conventional
Western approaches. What is less evident in the Western empirical
literature is that mindfulness meditation is grounded in a different
cultural context, primarily that of Asia, and is embedded in its own
sophisticated, comprehensive and time-tested psychological system.
This system expounds a far greater potential for health and
wellness than the Western research thus far has been able to indicate. In
the advancement of Western healthcare, Buddhist psychology with its
refined techniques of mindfulness meditation and self-healing, have much
to offer. And so this study has shown that popular demand and
professional receptivity towards integrative approaches are todays
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current trend in the field, and that mindfulness meditation represents a

cutting edge technique poised to become a more widely accepted
intervention (Baer, 2003).
CHAPTER 8: CONCLUSION
My objective in the present study was to examine and integrate
perspectives on the practice of mindfulness meditation from the areas of
Buddhism, medicine, neuroscience, and clinical psychology. I undertook
this project with the understanding that there has been a burgeoning
awareness among Western therapists, psychologists, and scholars, that
mental and physical health is contingent upon sustainable lifestyle
changes. This growing perception has contributed to an increase in the
study of Asian mind/body therapies that are time-tested in producing
cognitive-affective-behavioral insight and transformation (Loizzo, 2004,
2006b). In addition, managed care and the demand of Health Maintenance
Organizations (HMO) for empirically validated, noninvasive, timeefficient, and cost-effective health care alternatives have fueled a
renaissance of integrative and complementary treatments that meet these
standards (Dimidjian & Linehan, 2003). In response to public interest and
systemic need, currently there has been vigorous professional research on
the neuro-biological effects, clinical applications and evidence-based
efficacy of various meditation techniques, in particular, the ancient
Buddhist method of mindfulness (sati) (Baer, 2003; Banadonna, 2003;
Bishop, 2002; Brown & Ryan, 2003, 2004; Gremer et al., 2005; Grossman et
al., 2004; Hirst, 2003; Loizzo, 2000).
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195

Recommendations for Future Research

Methodological Rigor
The primary recommendation regarding future research in the area
of mindfulness meditation is that of greater methodological rigor. Though
Western meditation research has been conducted for more than 50 years,
there needs to be a greater number of well controlled, full scale clinical
trials to further validate initial findings of preliminary reports (Baer, 2003;
Bishop, 2002; Feldman et al., 2004). In their meta-analysis, Grossman et al.
(2004) reviewed over 60 studies on mindfulness but retained only 20
because of the lack of methodological accuracy. There are a few
noteworthy examples of reliable meditation research, such as Teasdale et
al. (2000) and Davidson et al. (2003), which could serve as standards for
future projects.
Specific Areas to Be Addressed
Future research in the field of mindfulness meditation research
should consider the following methodological issues to be of primary
importance:
1. An operationalized definition of mindfulness and an explicit reference
to the type of meditation practice being studied would provide
clarity and cohesion. In this way, the subjects and the findings of
the research could be organized into consistent classifications
according to their typology.
2. A clear indication would be helpful as to which meditation-based
intervention program was used (i.e., MBSR, MBCT, DBT, etc.).
Such an indication would present a breakdown of the length of the
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course, duration, frequency of the practice, and if extensive retreats

were included. These would eliminate any confusing variables
associated with divergent protocols.
3. Outcome measures, derived from standardized and validated scales,
need to be established with consistency so that data can be reliably
determined.
4. Use of a scale that measured the specific development of skill in
mindfulness would help in quantifying the dose response, and assist
in correlation analysis to isolate its effect. Examples of the scales
include the Freiburg Mindfulness Inventory (Buchheld, Grossman,
& Walach, 2001), the Mindful Attention Awareness Scale (Brown &
Ryan, 2003), the Toronto Mindfulness Scale (Bishop et al., 2003), the
Kentucky Inventory of Mindfulness Skills (Baer, Smith, & Allen,
2004), and the Cognitive and Affective Mindfulness Scale-Revised
(Feldman, Hayes, Kumar, & Greeson, 2003, 2004).
5. The collection and provision of data for all preintervention and
postintervention measures would permit researchers to calculate
the mean effect size for variables.
6. A control group would be useful for researchers in isolating the
nonspecific effects of meditation, including social support, demand
characteristics, and expectancy effects.
7. Postintervention data and follow-up at 6 months or more would
provide a much needed longitudinal perspective regarding
meditation adherence and long-term effects.

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8. Specific information regarding the training and background of the

meditation teacher or facilitator would help to clarify their
variables

from those of their subjects. In this way, personal and

professional traits that could influence program outcome would be

isolated.

Such influences would include years of meditation

experience,

specifics regarding meditation tradition and training, and

any

deviations they made from the meditation protocol. A large scale

study involving an expert meditation master from a particular
Asian meditation tradition (South East Asian, Indo-Tibetan
Buddhist or Hindu Yoga) has yet to be conducted.

9. Sample sizes that involved at least 30 participants could provide more

statistically significant effect sizes of medium or greater.
10. The maintenance of thorough records of the participants psychosocial history would augment any future developments of a profile
of meditation suitability.
11. Studies examining the effects of mindfulness meditation on medical
and clinical populations are in need of replication, but should be
complemented by research on healthy nonclinical samples in order
to understand its full potential and benefit.
Qualitative Data and Subjective Accounts
In addition to the above recommendations, given the scarcity of
subjective accounts of meditative experiences found in association with
the empirical literature, quantitative and experimental studies need to be
more fully complemented with sound qualitative or mixed
methodological designs. Such components as interviews, subjective
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reports, personal experiences, and open-ended questionnaires need to be

addressed as a way to increase the scope of available information. Some
researchers have conducted such qualitative and mix-design studies and
found that the qualitative aspects of the studies added substantively to the
information gained solely from the quantitative elements (Carlson et al.,
2001; Mason & Hargreaves, 2001). While quantitative reports indicated
that an actual effect was achieved, qualitative reports revealed specifics
regarding the manner and mechanisms by which this effect occurred.
These were seen to be significant areas of contribution, since the precise
mechanisms underlying mindfulness were still largely misunderstood
(Baer, 2003).
This subjective component has the capacity to bridge the gap
between the cross-cultural, methodological approach of Western empirical
objectivity, on the one hand, and Buddhist notion of valid cognition
(pramana), or first-person-objectivity, on the other. In the traditional
Buddhist context, according to ancient cartographies of consciousness,
subjective accounts of inner experience are an essential component of
meditation training, particularly for verifying mental development. Such
first-person accounts allow the meditation mentor/teacher (guru) to assess
and validate the psycho-spiritual achievement or regression of the
practitioner (B.A. Wallace, 2003).
Further Implications
Secular Versus Traditional Meditation
Most investigations of mindfulness meditation in the West,
particularly in the contexts of health and clinical applications, have
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involved the use of secularized versions, in which traditional spiritual

aspects have been removed. The consequences of secularizing meditation
practices, specifically of separating mindfulness meditation from its
Buddhist origins, have not been addressed adequately. How would the
presentation of mindfulness meditation change if the cultural and
spiritual origins were preserved? What might be gained in efficacy by
doing so or by not doing so? Is our responsibility to provide a secular
technique to the masses or to respect the ancient manner in which the
technique has been preserved for millennia? Is there a rationale and
necessity for both approaches to be available in the area of health and
clinical services? These are central issues that follow from the purpose and
tenets of this studythe examination of the origins of mindfulness
meditation and the potential for its reintegration in the Western context. It
is proposed here that, in order to address these questions, research into
traditional Buddhist meditation techniques that have not been diluted or
secularized when integrated into Western applications, such as MBSR and
MBCT, may reveal significant features that have been previously
neglected.
Qualifications of the Clinician
The use of mindfulness meditation in healthcare leads to questions
regarding the clinicians proficiency, competency, and training in its
applications, either secular or traditional. This question is significant,
given that meditation practices largely originate in nonwestern spiritual
traditions, such as Hindu yoga and Southeast Asian and Indo-Tibetan
Buddhism. Who will train Western clinicians how to use these different
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techniques? According to what standards and guidelines will clinicians be

taught meditation techniques to integrate in their clinical practice? How
will clinicians be monitored and to whom will they be accountable for
using these new techniques appropriately? Will there be separate training
and standards for secular and spiritually informed meditation
applications? If we closely examine clinical studies on meditation, it is not
clear what level of training and proficiency those providing instruction to
patients have achieved. There has not been a single study conducted by a
so-called master of an Asian meditation tradition, lineage or technique,
although preliminary efforts are underway to address this need (Santa
Barbara Institute for Consciousness Studies, 2005). While these areas have
not been sufficiently addressed, researchers have posed questions
regarding the clinicians ability to successfully convey meditation
instructions, particularly when they involve a spiritual dimension
(Dimidjian & Linehan, 2003; Roemer & Orsillo, 2003).
In order to evaluate these professional and practice issues, the
current study proposes that there should be a dialogue between clinicians
in the West and Buddhist meditation adepts, those individuals who
exhibit the most advanced meditative skills and accomplishments, as well
as scholars of traditional Buddhist psychology who are expert regarding
its theory and approach. Such a colloquy should include mutual
exchanges and inquiries in the areas of theory, clinical application and
empirical investigation to assist in clarifying the optimal ranges of
meditative potential for health and healing and for clinical training and
standards.
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Reintegration: A Return to Buddhist Origins

In some circles, there has been growing progress made in the study
of the Buddhist origins of mindfulness meditation and how it can be
applied to Western healthcare. During the last 2 decades, the Mind/Life
Institute has hosted a forum for dialogue between His Holiness the Dalai
Lama and prominent Western scientists and clinicians (Davidson &
Harrington, 2001; Goleman, 2003a, 2003b; Gyatso, 1997; Gyatso et al., 1991;
Hayward & Varela, 2001; Houshmand et al., 1999; Zojonc, 2004). This
forum has promoted a convergence of interest regarding techniques for
health and healing, cross-cultural research collaboration utilizing distinct
methodologies of meditation and neuroscience, as well as fostering a spirit
of mutual respect and human discovery.
Members of the Mind/Life Institute research consortium are
currently involved in three major studies examining the long-term effects
of traditional Buddhist meditation practices with large, nonclinical
samples of healthy people in the West. These studies include the Shamata
Project led by B.A. Wallace, evaluating long-term trait effects of
concentration or quiescence meditation on adults in an intensive year-long
meditation retreat; the Cultivating Emotional Balance Project led by
Kemeny and Ekman, examining the effects of compassion meditation on
healthcare providers; and, the UCLAs Mindful Attention Program (MAP)
Project, co-investigated by B.A. Wallace, examining the effects of
mindfulness meditation on attention deficit hyperactivity disorder in
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children, adolescence, and adults. The Santa Barbara Institute for

Consciousness Studies (2006), founded and directed by B.A. Wallace,
provided the following rationale for these innovative projects by
highlighting the limitations of previous research:
Over the past 30 years there have been numerous studies of the
psychological and physiological effects of meditation training, but
most of such studies have been based on fairly simple pre/post
(rather than longitudinal) research designs; focused on state rather
than trait (i.e., long-lasting) changes in mental abilities; focused on
physiological changes, such as indicators of relaxation, rather than
cognitive, sensorimotor, neurological, emotional, and ethical
changes; and were conducted before the advent of contemporary
social-cognitive and brain-imaging techniques, which allow
researchers to track changes in the mind and brain associated with
meditation training. In addition, the meditation techniques under
study were often not firmly grounded in a deep understanding of
ancient meditation traditions and not conducted over an adequate
period of time by an experienced instructor. For these reasons, we
still do not know a great deal about how professionally
administered meditation training of a particular kind, followed
over an extended period of time (as is common in the traditions
from which the meditation techniques are drawn), affects
attentional, sensorimotor, and emotion-regulation skills or ethical
responses to human suffering. (par. 2)
There is a growing interest in the traditional Buddhist mind
sciences and technologies among larger and more mainstream academic
audiences. In a speech that His Holiness the Dalia Lama (Gyatso, 2005)
presented to the Society of Neuroscience, he commented that the
convergence of Buddhism and modern health sciences had the potential to
make a significant contribution to human understanding. His Holiness
stated that this combined approach would enable scientists, physicians,
and scholars to further probe the complex inner world of subjective
experiences and lead to advances in cure and treatment. He mentioned
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studies in which mindfulness training and Buddhist compassion practices,

done on a regular basis, were bringing about changes in the human brain,
which were correlated to positive mental states and which could be
observed and measured. The Dalai Lama remarked
Already the benefits of such collaborations are beginning to be
demonstrated. According to preliminary reports, the effects of
mental training, such as simple mindfulness practice on a regular
basis or the deliberate cultivation of compassion as developed in
Buddhism, in bringing about observable changes in the human
brain correlated to positive mental states can be measured. Recent
discoveries in neuroscience have demonstrated the innate plasticity
of the brain, both in terms of synaptic connections and birth of new
neurons, as a result of exposure to external stimuli, such as
voluntary physical exercise and an enriched environment.
(Gyatso, 2005, para. 9)
Furthermore, His Holiness referred to the Buddhist contemplative
tradition as having the ability to expand the Western field of scientific
inquiry by proposing types of mental training that could also evoke
neuroplasticity. If it turns out, as the Buddhist tradition implies, that
mental practice can effect observable synaptic and neural changes in the
brain, this could have far-reaching implications (Gyatso, 2005, para. 9).
The repercussions of such research would not be limited only to the
growth of awareness regarding the human mind; they could have great
significance in the fields of education and mental health. In the same way,
the Dalai Lama found that Buddhist compassion had the capacity to lead
practitioners to a radical shift in outlook and to greater empathy toward
others, changes that offered far-reaching implications for society as a
whole. With the wider influence of Buddhism on popular culture and
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professional practice, we may expect to see adaptations in education and

training of those assigned to provide complementary healthcare services.
Dr. Joseph Loizzo, founding director of the Nalanda Institute for
Meditation and Healing in New York, represents a possible prototype for
the integrative health care practitioner of the future. A psychiatrist and
Ph.D. Buddhist scholar, Loizzo combines advanced academic training and
practice in two healing disciplines. Loizzos study of Buddhist
philosophy, meditation practices and Tibetan medicine, were based on
first hand knowledge of the original Sanskrit and Tibetan scriptures and
texts and was conducted within the context of close mentoring with adept
scholars of the Buddhist tradition. This knowledge base was combined
with conventional training in Western medicine, psychiatry and
psychotherapy to create a unique synthesis that respects and maximizes
both traditions equally.
After 30 years of research, Loizzo (2004) developed a meditation
manual consisting of a 24-week program of mindfulness meditation and
visualization techniques adapted directly from original Indo-Tibetan
Buddhist sources. These techniques are geared toward the cultivation of
cognitive-affect-behavioral learning and positive lifestyle changes for
Western medical populations and healthy, progress-oriented clients alike.
Unique to the program is the study, reflection and meditation practice of
selflessness, based on the so-called four-key analysis originally developed
by the venerated 14th-century Tibetan scholar Tsong Khapa, and available
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in a translation by Hopkins (Tsong Khapa, 1977). Loizzo et al. (2004), at

the Center for Integrative and Complementary Medicine at the WeillCornell Medical Center in New York City, conducted a pilot study in
which they examined the effects of this program on quality of life in a
breast cancer patient population. The preliminary data revealed
significant results in terms of symptom reduction and lifestyle
improvement, and Loizzo and colleagues have been awarded an
additional $250,000 grant by Avon to continue with a large scale clinical
trail.
Loizzos (2004) intervention program represented a departure from
all other previous meditation-based protocols (Hayes, Strosahl, et al., 1999;
Kabat-Zinn, 1982; Linehan, 1993b; Marlatt & Gordon, 1985; Segal et al.,
2002). Dr. Loizzo is the first to propose a completely traditional Tibetan
Buddhist curriculum rather than a diluted version integrated with
Western clinical approaches. Loizzos program preserves the three higher
trainings of lifestyle (sila), awareness (samadhi) and outlook (prajna), in
contrast to Western adaptations such as MBSR and MBCT that emphasize
the awareness training branch of the system exclusively. The program
also teaches advanced stages of mindfulness meditation and analytic
insight, used specifically to decondition the reified self-habit. In the late
1970s and 1980s Herbert Benson made famous the completely secular
relaxation response, which was followed a decade later by the Jon KabbatZinns MBSR, which combined Buddhist mindfulness with behavioral
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medicine. Loizzos protocol, in terms of the evolution of mindfulness

meditation research, has been decisive in bringing the clinical application
of meditation back to its unmodified traditional Buddhist origins, and
empirically investigating this reintegration. It is highly recommended
that contemporary Western researchers and clinicians continue this
direction of investigation and dialogue with Asian contemplatives and
Buddhist scholars.
Concluding Remarks
Given the growing clinical interest in mindfulness meditation, the
current study has attempted to provide a multiperspective review of its
theory, application and effects. The study has drawn attention to the
importance of respecting, acknowledging, and applying Buddhist
psychology as a valid and coherent therapeutic system in its own right,
rather than on extracting its essential ingredients for integration with
Western approaches. The limitations of the latter activity have already
been described (Loizzo & Blackhall, 1998).
This study pointed out that the empirical literature on mindfulness
meditation has not examined the benefits of this traditional Buddhist
practice to the fullest extent. The examination of Buddhist mindfulness
meditation, within its originating context in particular, drew attention to
the import of deregulating the self-habit (atmagraha). The central notion of
selflessness continues to be largely evaded in the Western research, except
by a few scholars who appear to possess training in both Buddhist and
conventional psychologies (Epstein, 2001; Loizzo, 2000; Rubin, 1996).
208

While the full potential of mindfulness to undercut egocentricity

has not been understood or utilized in the Western health context,
mindfulness has nevertheless been utilized effectively in medicine and
psychotherapy to deregulate cognitive-affect-behavioral patterns that
cause suffering. Western mindfulness research is still in its infancy and in
need of greater methodological rigor, yet there is an increasing consensus
regarding the empirical validity of mindfulness meditation in a diverse
range of clinical contexts. Additionally, mindfulness meditation meets
managed cares standard of being symptom-generalized, time-limited,
cost-effective, patient-friendly and manualized as a treatment protocol,
and thus holds enormous promise as a clinical intervention (Bishop, 2002;
Goleman & Gurin, 1993).
In the present study, the literature was found to support
mindfulness meditation as a unique method with the capacity to
therapeutically transform the body, brain, and mind. Current evidence
supports the ability of mindfulness meditation to elicit a relaxation
response that can counteract autonomic fight-flight reactivity, decrease the
likelihood of stress-prone physical illnesses and improve immune
functioning. Mindfulness meditation was found to activate the brains
right hemisphere leading to positive-affective states, arresting the longterm degradation of neural tissue caused by allostatic load, and
stimulating neural plasticity and repair. Mindfulness meditation was also
found to foster metacognitive-detachment and emotional-balance,
providing an integrated cognitive-affective-behavioral framework that
individuals could use to help them more effectively cope with physical
209

and mental stressors and illnesses. Finally, according to Buddhist sources,

mindfulness meditation could lead to a renunciation of the dissatisfying
nature of compulsive and habitual living, deautomatize unhealthy
outlooks, attitudes, and behaviors, and provide experiential relief by
supplanting ones identification and reification of a fixed self, with the
flexibility and openness of identity boundaries associated with insight into
selflessness.
The increased attention on mindfulness meditation in empirical
research, and its utilization in clinical contexts for a wide range of healthrelated issues, made a comprehensive review of the literature on this
subject both timely and significant. As future large-scale controlled clinical
trials are in preparation to correct the methodological weakness of
previous empirical research, the present study has tried to complement
quantitative findings by filling in theoretical gaps regarding the cultural
origins, traditional and conventional applications, causal mechanisms,
and potential benefits and limitations of this ancient technique.
In addition to documenting the growing popular interest, statistical
validity and clinical use of mindfulness-based interventions, this study
has attempted to draw increased attention to the Buddhist origins and
utility of this sophisticated centuries-old technique. Specifically, it is
proposed that clinicians and scientists, who seek to understand the
mechanisms and applications of mindfulness, should engage in a
systematic study of the traditional Buddhist psychological system and its
meditation practices and engage in dialogue with its representatives. In
this manner, it may be possible to gain greater access to the wisdom this
210

tradition possesses and the liberating effect that is its central therapeutic
massage. Empirical studies in the future will be responsible for shedding
light on any remaining benefits that have eluded Western research thus
far.

211

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APPENDIX A: ABREVIATIONS OF BUDDHIST TEXTS

Ap

Abidhamma-pitaka

As

Anapanasati Sutta

Bs

Bahiya Sutta

Dhp

Dhammapadda

Dcp

Dhammacakkappavattana Sutta

Jrv

Jaravagga Sutta

Kn

Kuddha Nikaya

Msp

Maha-satipatthana Sutta

Mpn Maha-parinibbana Sutta

Ss

Samadhi Sutta

Sn

Samyuta Nikaya

Sp

Satipatthana Sutta

Spv

Satipatthana-vibhanga Sutta

Stp

Sutta-pitaka

Stv

Sutta Vibhanga

Vp

Vinaya-pitaka

Ud

Udhana

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APPENDIX B: GLOSSARY OF BUDDHIST TERMS

Definitions by Author.
Abhidharma (Sankrit) Abhidhamma (Pali): Psychological Analyses. The
third part of the Buddhist Canon (tripitaka), the others being the ethical
teachings (vinaya) and the discourses of the Buddha (sutra). Contains a
systematic analysis of human psychology, personality and the nature of
reality.
Adhisiksya (Skt) also Trishiksya (Skt): Threefold Education. The three
higher trainings of Buddhist education: behavioral discipline (shila),
meditation (samadhi) and wisdom (prajna).
Anapanasati (Pali): Mindfulness of breathing. Alertness during inhalation
and exhalation.
Anatman (Skt) Anatta (Pali): No-self. Absence of a permanent,
unchanging, nonrelational self or soul. One of the three marks of existence
(trilakshana). In the Theravada the term refers to the nonexistence of the
permanent self. The illusion of a person consists of the five aggregates
(skhandas) but there is no essential self. The Mahayana adds the
nonsubstantiality of elements (dharmas) that constitute phenomenon.
Elements exist only by means of the union of conditions. There is no
eternal and unchangeable substance in them.
Arhat (Skt): Worthy one. One who has completely released all fetters. The
ideal or saint of the Hinayana tradition, who has eliminated both the
cognitive (asrava) and emotional (klesha) defilements that obstruct personal
liberation.
Ariya-sacca (Pali): Four Noble Truths. The central doctrine of Buddhism.
The Buddhas four phase therapeutic model of suffering including
symptom (Dukkha), diagnosis (Samudaya), prognosis (Nirodha), and
treatment (Ashtangika Marga). (a) Suffering exists, (b) and is caused by
misknowledge, (c) there is remedy know as nirvana, and (d) the way to
nirvana is an Eightfold Path that promotes morality, meditation, and
wisdom.
Avidya (Skt) Avijja (Pali): Delusion, misknowledge. The primary cause of
suffering according to the teaching of dependent origination (pratityasamutpada). One of the three poisons (the others being attachment and
aversion) that binds being to conditioned existence (samsara). In the early
schools (Hinayana) represents the misperception that self or personality is
separate and autonomous, and in the later schools (Mahayana, Vajrayana)
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is understood as ignorance of the fundamental relativity (shunyata) of all

phenomenon.
Bhavana (Skt): Familiarization or cultivation of the mind. The term refers
to meditation, an array of mental training techniques that access and
develop different states of consciousness.
Bodhicitta (Skt): Spirit of Enlightenment. The aspiration to achieve
perfect Buddhahood for the benefit of all living beings.
Bodhisattva (Skt): Enlightened hero. The ideal or saint of the Mahayana
who seeks perfect enlightenment through the practice of the 10 perfect
virtues (paramitas), but forgoes personal salvation until other sentient
beings reach this goal. The bodhisattva is characterized by his altruistic
intention/motivation (bodhicitta) as well as the wisdom of emptiness
(shunyata).
Buddha (Skt): The Awakened One. Any being who achieves
enlightenment (nirvana) and is freed from conditioned reality (samsara).
According to the Mahayana view, Buddha is the potential and essential
nature for awakening that exists in all sentient beings. The Buddha of this
historical age is known as Gautama Buddha or Shakyamuni Buddha, who
gained enlightenment in Gaya, India, around 560 B.C.E.
Buddhisodhana (Skt). Meditative self-correction. In the Mahayana, deobjectifying intuition guided by language therapy combine to create a
critical method of self-correction.
Chakra (Skt): Elaborate subtle body or nonphysical nervous system
containing neural complexes (chakra), neural energy (prana), neural
pathways (nadi), and neurotransmitters (bindu).
Dharma (Skrt) Dhamma (Pali): Various meanings including the truth in
regards to the nature of things; the law as related to karmic causality;
the sacred teaching of the Buddha which reveal the essential qualities of
suffering and salvation.
Dhyana, Jhyana (Skt): Meditative absorption. Generally any absorbed
state of mind that results from concentration meditation (samadhi).
Specifically refers to four stages of absorption in the form realm in which
the following states are subverted as ones trance progresses: sympathetic
joy (mudita), loving-kindness (metta), compassion (karuna) and equanimity
(upeksha).
Dukkha (Skt): Dissatisfaction, suffering. Central concept in Buddhism,
which lies at the root of the Four Noble Truths. The three characteristics
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of reality (trilakshana) are that phenomena lack autonomous self-essence

(anatman and shunyata) and are therefore impermanent and transitory
(anitya) and are therefore dissatisfying (dukkha) and not to be relied upon.
Dukkha also refers to everything that is conditioned and therefore not
liberated.
Guru (Skt): Spiritual teacher, mentor, guide.
Kalyanamitra (Skt): Spiritual friend. May include Gurus, virtuous
friends, wise persons, Bodhisattvas, Buddhas, anyone who can help the
practitioner progress along the path to enlightenment.
Karma (Skt): Action. Habitual action or conditioned behavioral patterns.
The universal law of cause and effect. Based on causality (pratityasamutpada) an individuals volitional intention produces a specific result,
which can ripen in this or a next life and which also predetermines future
intentions.
Karuna (Skt): Compassion. Central motivation in Mahayana Buddhism,
where it is viewed as indispensable from the realization of emptiness
(shunyata).
Klesha (Skt) Klesas (Pali): Defilement. Addictive emotions. Maladaptive
emotional responses.
Mahayana (Skt): Great Vehicle. One of the three major schools of
Buddhism, the other two being the Way of the Elders (Hinayana) and the
Adamantine Vehicle (Vajrayana). Commonly found in Tibet, China, Japan,
Korea and other East Asian Countries. Arose during the 1st-century C.E.,
and distinguishes it self from the early schools in a number of ways
including less emphasis on monasticisms and personal salvation, and
more emphasis on universal responsibility and social liberation.
Characterized by its revolutionary understanding of emptiness/relativity
(shunyata) it critiques and revises many of the traditional teachings and
holds compassion as its central virtue.
Mantra (Skt): Incantation, mental command, mnemonic spell,
concentration formula. Sanskrit word meaning uniting and holding, that
is, uniting all truths regarding reality (dharmas) and holding all meanings.
Mudra (Skt): Hand gesture in meditation or ceremony, each representing
or suggesting a specific meaning.
Nirodha (Skt): Destruction. Dissolution of the cognitive and affective
obstacles to enlightenment. The Third Noble Truth that proclaims the
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possibility to be free from suffering, to enter into nirvana, specifically by

eliminating the causes of future rebirth.
Nirvana (Skt): Extinction. The ultimate realization in all schools of
Buddhism. In early Buddhism (Hinayana) it refers to a release from cyclic
conditioned existence (samsara) requiring the complete overcoming of the
three poisons (ignorance, desire, and hatred), addictive emotions (klesha)
and the determining effect of action (karma). Nirvana is unconditioned
and is characterized by an absence of arising, subsisting, changing and
passing away. In the later school (Mahayana) nirvana is seen as
inseparable from conditioned reality (samsara) based on a nondual
understanding developed through the insight into relativity (shunyata).
Nirvana is conceived as the union of bliss and openness inherent and
ever-present in all things.
Prajna (Skt): Wisdom. Super knowing. Insight into the true nature of
things, associated with emptiness (shunyata) and as a prerequisite for
enlightenment (nirvana). The suffix jna comes from the same root as the
term gnosis.
Pramana (Skt): Valid cognition. Indian epistemological systems rely on
refined subjective awareness as a valid means of investigating the nature
of self and reality. Also known as subjective-objectivity and first-person
objectivity.
Pratitya-samutpada (Skt): The law of causal interdependence also known
dependent origination, conditioned genesis, or interrelated causality.
Central teaching of all schools of Buddhism, which accounts for the
appearance of reality and the self through the mutual arising of 12
interdependent factors. Describe how reality is interrelated, and is later
equated with emptiness (shunyata), as phenomenon possesses no
autonomous or intrinsic essence.
Rupa (Skt): Body, material form, or the five elements of physical reality.
Sadhana (Skt): An esoteric or Tantric meditation practice involving
rituals, visualization, invocation, and recitation of mantras.
Samadhi (Skt): Nondual absorption. The culmination of the Path of
Concentrative in an ecstatic experience of union with the meditative
object. Samadhi dissolves subject-object dualism, but remains a
conditioned state from which one must return to the state of the desire
realm (kamloka).

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Samsara (Skt): Refers to cyclic existence from one rebirth to the next in a
state of suffering and dissatisfaction (dukkha), propelled by delusion,
attachment and aversion. Conditioned or unenlightened existence. The
type of rebirth in samsara is determined by action (karma) and can be
liberated from through the realization of shunyata and nirvana.
Samskara (Skt) Sankara (Pali): Mental tendency, mental formation, or
mental construction. Generally referring to the way thought patterns and
constructs are formed and fashioned. One of the five aggregates
(skhandas) of personhood.
Sati (Pali) Smirti (Skt): Mindfulness, alertness, attentiveness,
remembering.
Satipattana (Pali): Meditation technique developed by the Buddha and
unique to Buddhism, which calls for an even flowing nonjudgmental
attention of the body, feelings, mind states, and thoughts of the present
moment. Is said to be the necessary method that leads to enlightenment.
Satipatthana Sutta (Pali): Famous meditation text on the four foundations
of mindfulness also translated as the four frames of reference, found in
Digha Nikaya, the Long Discourses of the Buddha.
Shamata (Skt) Samatha (Pali): Tranquility. Concentration meditation
technique that focuses awareness on one specific subject, often inducing
trance-like states (dhyana), calmness and equanimity, and culminating in
absorption (samadhi). The common feature of all meditation systems
developed throughout the world.
Shila (Skt) Sila (Pali): Morality, behavioral discipline. Refers to the ethical
guidelines set down for the moral conduct of monks and nuns. Is the
foundation of the three higher trainings (trishiksha), in which ethical
conduct serves to stabilize the mind and prepare it for intellectual and
meditative learning.
Shunyata (Skt): Voidness, Emptiness. The central notion of the Mahayana
that revolutionized Buddhist thought and practice, proposed most
eloquently by the scholar sage Nagarjuna. The concept goes a step beyond
the limited meaning of no-self (anatman), to imply a lack of absolute
essence and autonomy in all phenomena. It is because of this lack of
essentiality that all things can relate, and therefore has been equated with
the notion of relativity.
Skandas (Skt) Kandhas (Pali): Aggregates. Term for the five systems that
constitute what is generally known as personality. They are (a) material
form (rupa), (b) sensation (vedana), (c) perception (samjna), (d) mental
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formations (samskara), (e) consciousness (vijnana). The characteristics of

the skandhas are birth, old age, death, duration and change. They are
regarded as without intrinsic essence (anatman), are relational (shunyata),
impermanent (anitya) and dissatisfactory (dukkha).
Smirti (Skt): See Sati.
Sukkha (Skt): Bliss, joy, happiness or peace. A state of mind cultivate
through concentration meditation (shamata). Experienced as one of the
divine abodes (brahma vihara) of the form realm (rupaloka).
Sutra (Skrt) Sutta (Pali): Formula, sermon, teaching, discourse, text or
scripture.
Stupa (Skt): Reliquary. Typically dome shaped, burial mounds
containing relics of the Buddha or other enlightened beings that serve as
places of veneration, ceremony and pilgrimage.
Tantra (Skt): Sacred text or methods containing esoteric knowledge and
practices.
Tatagatha-garba (Skt): The embryo of enlightened potential. The innate
Buddha-nature present in all beings obscured by defilements.
Theravada (Skt): The Way of the Elders. The last surviving of the original
18 Hinayana schools that preserved the classical Pali Canon (tripitaka).
Represents the original Buddhist movement developed in the first 5
hundred years after the Buddhas death. Commonly found in Thailand,
Sri Lanka, Burma and Cambodia. Holds renunciation as it primary virtue,
the arhant as it ideal and strives for individual liberation.
Trilakshana (Skt): Three marks of existence: impermance, selflessness
and dissatisfaction. Reality is said to be impermanent (annicca) because it
lacks enduring essence (anatman) and is therefore unreliable and produces
suffering (dukkha).
Trilokas (Skt): Three realms of consciousness: desire realm (kamaloka) of
ordinary suffering, the form realm (rupaloka) of sublime states (brahma
vihara) and positive emotions, and the formless realm (arupaloka) of
meditative absorption.
Tri-Pitaka: Three baskets or collections of the Pali Canon consisting of the
Vinaya Pitaka (scriptures on discipline), the Sutta Pitaka (scripture of the
Buddhas sermons), and the Abhidhamma Pitaka (scriptures on Buddhist
psychology).
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Trishiksha (Skt) also Adhishiksha (Skt): Threefold Education. The three

higher trainings of Buddhist education consisting of moral ethics and
behavioral discipline (shila), meditative skill and attentional control
(samadhi) and wisdom and experiential insight (prajna).
Upaya (Skt): Expedient technique, skillful means. Refers to strategies,
methods, devices targeted to the capacities, circumstances, likes and
dislikes of each sentient being, so as to effectivly lead them to
enlightenment.
Upadana (Skt): Compulsive behaviors. Attachment to the five aggregates
of being (skandhas) that leads to suffering.
Vajrayana (Skt): Adamantine or Apocalyptic Vehicle. One of the three
main divisions of Buddhism, which arose in north India around the
middle of the first millennium. It was transported to many of the same
countries as the Mahayana including parts of East Asia but is practiced
predominantly in Tibet, Mongolia, Bhutan and Sikkim. It incorporates
both monastic and social forms of practice, but is distinguished by the
inclusion of esoteric, highly developed ritual practices known as Tantra.
Vedana (Skt): Feeling. Any sensation falling between the extremes of
pleasure (ease) and pain (stress) including neural sensations or absence of
feeling.
Vichara (Skt): Evaluation. Scanning awareness. In meditation, vicara is the
mental factor that allows one's attention to shift, scan and move about in
relation to the chosen meditation object. It is closely related to direct
thought (vitarka).
Vijnana (Skt) Vinnana (Pali): Consciousness, cognizance. The act of
taking note of sense data and ideas as they occur. One of the five
aggregates (skandhas) that constitute the illusion of personhood.
Vinaya (Skt): The precepts for monks and nuns, designed to help them
eliminate defilements. Vinaya Pitaka refers to the body of ethical rules and
disciplines for Buddhist monks and laypersons prescribed by the Buddha.
One of the three collections contained in the Buddhist Pali Canon
(Tripitaka), the other two being the Buddhas discourses (sutras) and
psychological commentaries (abhidharma).
Vipassana (Pali) Vipashyana (Skt): Insight, clear seeing. In the Hinayana
refers to the intuitive realization of the three marks of existence
(trilakshana), while in the Mahayana refers to an examination of the nature
of things leading to insight into emptiness (shunyata). A meditative
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technique that incorporates calm-abiding or concentration practice

(shamata/samadhi) with mindfulness (satipattana) and discursive analysis.
Develops the necessary skill for cognitive/affective relearning and is the
prerequisites for awakening (bodhi).
Vitarka (Skt): Directed thought, concentrated attention. In meditation,
vitarka is the mental factor by which one's attention is applied to the
chosen meditation object. Closely related to evaluation (vichara).
Yanas (Skt): Vehicles. Metaphor for the Buddhas teaching that carries all
living beings to enlightenment and liberation. There are three vehicles,
the Lesser Vehicle (Hinayana, Theravada) designed for individual
liberation, the Greater Vehicle (Mahayana) designed for social liberation
and the Adamantine Vehicle (Vajrayana, Tantrayana) designed for
expedient liberation of individual and collective simultaneously.
Sometimes there is mention of only Two Vehicles, one for the Sravakas and
Pratyekabuddhas who aspire for solitary enlightenment and a second for
Bodhisattvas and Buddhas who completely realize ultimate reality.

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