Cognitive-Behavioral Therapy (CBT) has been shown to be an efficacious treatment for a wide range of psychological disorders. In the last three decades, there has been a fruitful and successful integration of Buddhist thought and practices in CBT through the concept of mindfulness. Mindfulness is actually only one of the eight contemplative practice guidelines of the Middle Way, a pan-Buddhist principle for overcoming suffering and generating happiness. Hence, in Western literature, although the integration of the mindfulness concept was successful, it is rather narrow and does not reflect the complexity of mindfulness as in Buddhism. This may have impeded the use of its full potential in clinical practice. This article therefore will highlight the lesser known aspect of mindfulness (Right Mindfulness) in the Middle Way and its synergistic relationship with the other seven practice guidelines (i.e., Right Speech, Action, Livelihood, Effort, Concentration, Thought, and View). We then propose their potential integration and application in an evidence-based CBT approach. It is suggested that by integrating this broader meta-mindfulness approach, further advances in CBT practices, research, and training can be made to benefit the human race.
Over the years, Cognitive-Behavioral Therapy (CBT) has gained a great deal of empirical evidence for treatment of various medical and psychological disorders (Chambless and Ollendick 2001; Oei et al. 1999; Oei and Dingle 2008), and CBT is now widely accepted as an evidence-based psychotherapy for many of the psychological disorders. But there have been some criticisms about this approach, including that it may be difficult to differentiate between CBT and other forms of psychotherapy at the practical level. However, the meta-analysis by Blagys and Hilsenroth (2002) has nicely summarized the distinctive processes of CBT: (1) the use of homework outside therapy sessions, (2) the direction of session activities, (3) the teaching of skills for coping with symptoms, (4) the focus on the client’s present and future experiences, (5) the provision of information about a client’s disorder, and (6) the focus on a patient’s illogical or irrational thoughts or beliefs. Thus, it has been empirically shown that CBT can be distinguished from other psychotherapies, which provides a firm basis for further expansion of CBT treatment. A recent development of CBT treatment is in the area of mindfulness-based CBT.
In the last three decades, there has been a fruitful synthesis of Buddhist thoughts and practices in CBT through the concept of mindfulness. This has resulted in the rebirth of a third wave of behavioral treatments (i.e., mindfulness-based CBTs), the first being behavioral therapy and the second being Cognitive-Behavioral Therapy (Hayes 2002). Though not universally accepted as third-wave treatments (Hofmann and Asmundson 2008), these mindfulness-based CBTs (Mace 2007) include mindfulness-based stress reduction program (MBSR; Kabat-Zinn 1990), mindfulness-based cognitive therapy (MBCT; Segal et al. 2002), dialectical behavioral therapy (DBT; Linehan 1993), and acceptance and commitment therapy (ACT; Hayes et al. 1999). MBSR is relatively more experiential in nature and does not focus on a traditional way of thoughts management (i.e., challenging thoughts). However, it is considered here as a form of CBT by the authors of this paper as it shares many similarities with the distinctive processes of CBT as described by Blagys and Hilsenroth (2002). Kabat-Zinn has warned against mindfulness being “seized upon as the next promising cognitive behavioral technique or exercise.” (Kabat-Zinn 2003). But it was done in the context of emphasizing the importance of personal mindfulness practice and acceptance-based approach. It has now been shown that change-based and acceptance-based approaches can be successfully integrated in CBT (Lau and McMain 2005; Hofmann and Asmundson 2008).
These mindfulness-based CBTs have gained significant empirical support for their efficacy. To date, there are at least 18 randomized controlled trials (RCTs) on MBSR for the improvement of physical and psychological symptoms (Grossman et al. 2004; Keng et al. 2011), 13 RCTs on DBT mainly for borderline personality disorder (Lynch et al. 2006; Keng et al. 2011), 14 RCTs on MBCT mainly for the prevention of recurrent depression (Chiesa and Serretti 2011), and 18 RCTs on ACT for various psychological disorders (Powers et al. 2009). Meta-analytic review in patients with anxiety and depressive disorders shows that MBSR and MBCT have large effect sizes (Hedges’s g of 0.97 and 0.95) for improving anxiety and depressive symptoms (Hofmann et al. 2010). ACT has been shown in two RCTs to reduce the believability of psychotic symptoms and re-hospitalization rate of patients with psychosis (Bach and Hayes 2002; Gaudiano and Herbert 2006).
Since its inception, CBT has always incorporated scientific methodology and thus has kept expanding its constructs and techniques by continuous experimentation. Mindfulness is one of these concepts that have been successfully integrated into CBT and is gaining acceptance in the Western literature as demonstrated by the various forms of mindfulness-based CBTs mentioned earlier. While integrating mindfulness techniques has certainly enriched the conceptualization and practices of CBT, it also has some limitations. The major limitations will be explored here, and thus, the aim of this paper was to expand the concept of mindfulness as it is taught in the Middle WayFootnote 1, a pan-Buddhist principle whereby mindfulness is a central component. It is suggested that by expanding mindfulness into meta-mindfulness and integrating the concept of meta-mindfulness into CBT, further advances in CBT can be made. Before expanding and integrating the concept of meta-mindfulness into CBT, the next section will briefly summarize the current concept of mindfulness as integrated in mindfulness-based CBT.
Mindfulness and Mindfulness-Based CBT
In a clinical context, mindfulness was first conceptualized by Kabat-Zinn as “paying attention in a particular way, on purpose, in the present moment, and non-judgmentally” (Kabat-Zinn 1994). Since then, many definitions and concepts of mindfulness have evolved, and until now, there is still no definite consensus on it (Baer et al. 2008; Bishop et al. 2004; Brown et al. 2007). Having said that, in mindfulness-based CBT, generally, there is more emphasis on changing the relationship with negative automatic thoughts (AT) and other mental events, embracing them with a sense of compassion and curiosity instead of actively challenging them as in traditional CBT (Segal et al. 2002).
Mindfulness-based CBT training aims at acquiring the skill to gently “de-personalize” one’s mind–body events, e.g., thoughts, feelings, bodily sensations. What does this mean? As an example, an individual with the negative AT, “I’m useless, I’m a burden to others!” is trained to mentally watch the thoughts from a distance with an attitude of curiosity, non-aversion, and understanding that the stream of thoughts, memories, or images are just mental events instead of personal solid facts. They are transient, erroneous, and conditioned phenomena instead of absolute truths carved in stone. Though no overt thought-challenging techniques (e.g., Socratic questioning) are involved, this has also been shown to be able to neutralize and prevent thoughts from proliferating, becoming emotionally charged, and escalating into destructive affective states.
Several studies have supported the fact that actively suppressing a thought, feeling, or bodily sensation, including pain, will ultimately increase it (Cioffi and Holloway 1993; Clark et al. 1991; Gold and Wegner 1995; Wegner et al. 1987, 1991). This might explain the clinical observation that some patients do not do well with active thought challenging as when they focus more on their thoughts, they reinforce their thoughts, and thus make their thoughts more salient. Furthermore, in some depressed patients, pointing out deficits in their thinking, as an exclusive focus, may be counterproductive and may rupture the therapeutic alliance (Burn and Nolen-Hoeksema 1992). This may also be one reason for some adults to prematurely terminate CBT treatment (Oei and Kazmierczak 1997). Mindfulness-based CBT is helpful in overcoming some of these challenges. The final desired outcome of mindfulness-based CBT is the transformation of emotions as in traditional CBT, but the mechanism and process involved is more of passive acceptance-based rather than active change-based. Lau and McMain (2005) have described that both strategies can be harmoniously integrated, as has been done in MBCT and DBT. This non-dichotomous approach is indeed more consistent with the spirit of the “Middle Way.”
This mindfulness or acceptance-based approach of relating to negative ATs and mental processes has been creatively described through various similar concepts: decentering (Safran and Segal 1990), detachment (Bohart 1983), deautomatization (Deikman 1982), observing self (Deikman 1982), creative cognitive process (Langer 1989), cognitive defusion (Hayes et al. 1999), and mental freedom (Krishnamurti 1964). Wells (2005) has further conceptualized mindfulness as cognitive information processing of thoughts and internal events in the absence of conceptual analysis and in the absence of goal-directed responses. It has five characteristic features, which are (1) meta-awareness (consciousness of thoughts), (2) cognitive decentering (comprehension of thoughts as events instead of facts), (3) attentional detachment (attention is flexible and not anchored to any one event), (4) low conceptual processing (low levels of analytical and meaning based appraisals, i.e., inner dialogue), and (5) low goal-directed coping (goals to remove or avoid threat are not paramount).
The skill to be mindful is introduced and reinforced in mindfulness-based CBT through various interrelated methods: psychoeducation and discussion; formal meditation practice (e.g., mindful breathing, body scan, mountain and lake meditation); experiential exercises (e.g., mindful eating, yoga stretch, and cognitive defusion techniques such as using AT as lyrics to sing a song or rapidly repeating aloud AT for a hundred times); use of metaphors (e.g., allowing thoughts and moods to come and go, as birds and clouds in the sky or leaves flowing in a stream); observing sensory experience with a beginner’s mind attitude (e.g., paying attention to sounds such as clocks tickling, birds chirping, or cars passing); describing/labeling with words (e.g., naming emotions such as anger, describing conflicting thoughts, and expressing expectations); living fully in the present moments or acting with full awareness in daily activities (e.g., eating, standing, walking, talking, listening); non-judging and non-reactivity to inner experience (e.g., embracing unpleasant experience with kindness and watching thoughts and feelings without getting lost in them), etc. A detailed description of the similarities and differences of the approaches used in the various mindfulness-based CBTs is beyond the scope of this paper and has been well described elsewhere (Chiesa and Malinowski 2011; Mace 2007).
Mindfulness, particularly in DBT, has also been conceptualized as an acceptance-oriented attitude for therapists to cope with the frustrating limitations of patients, other therapists, and therapists themselves (Linehan 1993). This is particularly important in dealing with patients with borderline personality disorder. Therefore, mindfulness-based therapists are always encouraged to have personal mindfulness practice to improve their ability to use experiential knowledge to teach mindfulness skills and also as a personal coping skill. Mindfulness-based intervention has been shown to be effective for preventing burnout and compassion fatigue in healthcare professionals (Shapiro et al. 2005) and stress reduction in trainee psychotherapists (Shapiro et al. 2007). Interestingly, psychotherapists in training who practiced mindfulness had better treatment outcome for their patients (Grepmair et al. 2007).
From Mindfulness to Meta-mindfulness
Although the concept of mindfulness is now very popular in Western literature and has also received empirical support, there is valid concern that the actual meaning of mindfulness in the context of psychotherapy is gradually being diluted, and there are significant common confusions over it (Mikulas 2010; Thanissaro 2008). The selective import of the concept of mindfulness from its spiritual root in Buddhism into Western psychotherapy could have also resulted in the loss of some of its “active ingredients” (Kang and Whittingham 2010; Rosch 2007; Wallace 2008). The authors of this paper concur with these views and further propose and describe in greater detail that it is more helpful to understand mindfulness in a bigger context (meta-mindfulness), which is in the context of the Middle Way. Understanding of mindfulness in the bigger context of meta-mindfulness will thus allow for the further integration of Buddhist thought into CBT and the advancement of CBT.
The current concept of mindfulness in psychotherapy has already evolved from one construct, i.e., attention/awareness (Brown et al. 2007), to two constructs, i.e., attention/awareness and attitude (Bishop et al. 2004), to three constructs, i.e., attention/awareness, attitude, and intention (Shapiro et al. 2006), to five constructs, i.e., (a) bare attention, attention control, intention, ethical discernment, and wholesome emotions (Dorjee 2010) and (b) observing, describing, acting with awareness, non-judging, and non-reactivity (Baer et al. 2008). If the constructs of mindfulness are intended to be expanded in this way, we might as well do it fully in the form of “meta-mindfulness.”
Before moving on to the next section, it is useful to be aware of the major interrelated differences between the current conceptualization of mindfulness in mindfulness-based psychotherapies and Buddhism: (1) Mindfulness in Buddhism is often cultivated together with other contemplative practices, e.g., contentment, equanimity, and selfless service, which will be highlighted in this paper. Even though the current conceptualization of mindfulness has implicitly included some of these practices, they are relatively dormant. (2) It has an emphasis on the memory construct, reminding us to pay introspective awareness (thoughts, emotions, bodily sensations, behavior) and observe life phenomena (birth, old age, sickness, death) according to Buddhist teachings such as “unsatisfactoriness,” “impermanence,” and “non-self.” These again will be highlighted under Right View in this paper. (3) As each Buddhist tradition has different emphases on the Buddha’s teaching, the flavor of mindfulness varies slightly in different Buddhist traditions: In Theravada Buddhism, it is cultivated with the views of impermanence, suffering, and non-self. As for Mahayana Buddhism, it is associated with the views of “emptiness,” “dependent origination,” “Buddha nature,” and with the intention of perfect enlightenment for all sentient beings (Wallace 2008). Finally, in Vajrayana Buddhism, it is directed at cultivating “clear light” mind that realizes the “emptiness” nature of existence (Kang and Whittingham 2010). (4) It invariably has a psycho-ethical component and coexists with other wholesome mental states. Even in the Tibetan Abhidhamma whereby mindfulness is a neutral mental factor (Cullen 2011), it is intended for the cultivation of wholesomeness (Kang and Whittingham 2010). As mentioned earlier, Right Mindfulness is the term used in Buddhism to highlight the fact that mindfulness skill when developed with a wrong intention, e.g., creating more violence in the world, cannot be considered the proper kind of mindfulness that leads to the alleviation of existential suffering. (5) Mindfulness training in Buddhism is often skillfully balanced with other mental cultivation techniques according to individual temperament. For example, loving-kindness meditation is recommended for those with propensity toward anger (Dorjee 2010; Gilpin 2008; Olendzki 2008; Rosch 2007).
The present concept of mindfulness is too narrow and may not be able to achieve its full potential in the integration of mindfulness with CBT for the benefit of reducing suffering and personal growth. Thus, we intend to expand the concept of mindfulness into meta-mindfulness with the hope that this expansion would allow the full integration of Eastern philosophy with CBT. By further integrating meta-mindfulness in the context of Middle Way (MW) onto CBT, some researchers and clinicians might suggest that we are bringing Buddhism into CBT. We would like to emphasize that this paper is not intended to convert researchers and clinicians into followers of Buddhism but to show that meta-mindfulness can be creatively integrated into CBT, just as mindfulness has been done successfully with minimal or no religious tone of Buddhism. We further suggest that it has tremendous implications for future theoretical advancement, practice, and research in CBT.
Though in a general sense mindfulness has been proposed as a common factor across all schools of psychotherapy (Martin 1997) and is partly embedded in various contemplative and philosophical traditions, the more specific concept of mindfulness has its roots in the Middle Way (Majjhimā Patipada) of Buddhism. In the Buddhist Pali Canon, MW refers to the Noble Eightfold Path, a pan-Buddhist principle (common in all major Buddhist traditions), but a non-theistic and non-faith-dependent contemplative practice guideline for overcoming suffering and achieving happiness in life. The MW is part of the Four Noble Truths that are the heart of Buddhist teachings: (1) Suffering is ubiquitous, (2) Suffering is a consequence of psycho-spiritual ignorance resulting from a distorted perception of realities in life, (3) The cessation of suffering is possible, and (4) The path to the cessation of suffering is the Middle Way or Noble Eightfold Path (Kumar 2002).
The eight interrelated, interdependent, and overlapping MW guidelines consist of Right Speech, Action, Livelihood, Effort, Concentration, Mindfulness, Thought and View (Fig. 1). As can be seen from Fig. 1, the guidelines of MW or Noble Eightfold path are interrelated in a circular way.
From a CBT perspective, the first three are behavioral guidelines and the subsequent five are cognitive–affective or mental cultivation guidelines. The latter is considered the pinnacle of MW practice, and mindfulness meditation is part of it. It is interesting to note that the currently popular concept of mindfulness in modern psychotherapy is only one of the eight practice guidelines from the MW. Therefore, for greater therapeutic potential of mindfulness-based CBT, it may be useful to explore the other seven “therapeutic siblings” of mindfulness and see how the clinical concept of mindfulness can be expanded into meta-mindfulness and elaborate the potential of further integration and benefit to CBT.
In Buddhist psychology, there seems to be no clear dichotomy of cognition and affect as practiced in modern psychotherapy (Ekman et al. 2005). Research in neuroscience has supported this by demonstrating that the neurochemical circuits that support affect and those that support cognition are completely intertwined. Every region of the brain that has been identified to be associated with cognitive states has also been identified to be associated with affective states (Davidson and Irwin 1999). In a way, cognition is like the lyrics of a song and affect is like the melody of a song. Therefore, the compound word “cognitive–affective” is often used in this article to describe the MW (the five latter steps) from a CBT perspective.
The following sections will discuss the eight practice guidelines of MW from a CBT perspective. It is important to note that CBT started in the West and thus tends to conceptualize constructs in a linear fashion. MW started in the East and thus conceptualizes constructs in a circular mode, just like the ying and yang concepts (see Fig. 1). Even though the MW is presented here in a sequential manner, the eight guidelines are best perceived as eight spokes of a turning wheel connected by a central hub (Fig. 1), interdependent and mutually supporting one another, leading us away from suffering and into peace and happiness. The next section will discuss in detail the three behavioral guidelines of MW and how these can be integrated into CBT to enhance the clinical practices of “meta-mindfulness-based CBT.”
Right Speech, Action, and Livelihood
These are the behavioral guidelines of the MW for the purpose of moral self-restraint (Fig. 1). The word “morality” often triggers unpleasant feelings. This is understandable as it is often linked with the fear of punishment, guilt, and conflict over what constitutes moral or immoral actions, which are all unnecessary or even harmful in therapy. Hence, it is crucial to appreciate that the moral self-restraint in MW is conceptualized as a rational guide for harmonious living and not as a set of dogmatic and punitive rules. It should be correctly perceived as a form of secular ethics in the spirit of non-violence and respect.
It has two dimensions: an abstinence part (e.g., avoiding the act of stealing) and a performance part (e.g., offering voluntary service). Though the finer aspects of morality are subjected to individual and cultural interpretations, we can all generally agree that certain antisocial or pro-violent traits like killing, stealing, rape/sexual misconduct, lying/cheating, and substance abuse (related to the five Precepts, i.e., the fundamental code of Buddhist morality—abstinence part) are detrimental to mental and social health. Conversely, kindness, generosity, sexual responsibility (non-violence and respect in sexual relationships), truthfulness, and clarity of mind (related to five Ennobling Virtues, i.e., the fundamental code of Buddhist morality—performance part) are conducive for harmonious living and peace of mind.
Behavioral prescription is no doubt part and parcel of CBT. But it seems uncommon for CBT therapists to offer collaborative moral-based recommendations, as though it is outdated and unprofessional. On the other hand, morality as a concept of harmonious living is the foundation for mental cultivation in the MW, where the idea of mindfulness mainly originated. Without a reasonable foundation in morality, there may be significant psycho-spiritual hindrances (e.g., anger, guilt, fear, doubt) that interfere with mindfulness and other mental cultivation guidelines of MW. It is not too difficult to imagine the difficulties (e.g., craving, guilt, worry) that a patient with drug addiction and pending police investigation for crimes would face when engaging in mindfulness-based therapies.
For patients with such psycho-spiritual hindrances, MW will recommend some forgiveness- and repentance-based exercises prior to other more intense mental cultivation practices (see Table 1). This is how the moral–behavioral guidelines of MW can be appropriately integrated to support mindfulness-based CBT. One MBSR program for medical students (Shapiro et al. 1998) has indeed included loving-kindness and forgiveness meditation (including self-forgiveness) in its training. Such preparatory work for further mindfulness practice should not be taken lightly in psychotherapy. After all, self-acceptance of mistakes has also been seen as part of mindful cognition (Carson and Langer 2006), and this resonates well with the MW.
Furthermore, a moral-based behavioral self-restraint by itself, if done with Right View (i.e., as guides for harmonious living instead of strict punitive rules), can potentially transform negative AT and condition positive states of mind. For example, a depressed person may think, “I’m harmless and can control myself. People trust and respect me. Not only that, I’m capable of helping others in the community. Yes! I’m really not that useless after all.” This could enhance self-esteem, life satisfaction, and a positive sense of connectedness. It is delightful to know that effort has actually been made in positive psychology to systematically classify human strengths and virtues and to determine how they can be integrated into clinical practice to buffer psychological distress and promote happiness (Duckworth et al. 2005). Such an effort is also strongly consistent with the philosophy behind MW.
It is also encouraging to know that “ethical discernment” has recently been proposed as one of the five dimensions of mindfulness for further research (Dorjee 2010). This is not entirely new as MBSR/MBCT training does involve an implicit sense of ethics even though not as directly discussed in MW. Two out of the six core processes in ACT training are “valued direction” and “committed action.” Spirituality is also explicitly listed in ACT as a domain of meaningful life directions and commitments (Hayes et al. 2006). As for DBT, one of the “how” mindfulness skills is “effectiveness,” which is to focus on doing what works rather than what is “right” versus “wrong” or “fair” versus “unfair” (Linehan 1993). These are “effective” models to introduce ethical discernment. We do not go around killing, raping, and cheating people because it is not an “effective way” of living; it is not just because God says so or it has bad karmic consequences in doing so. Therefore, the moral–ethical part of MW can be skillfully enhanced in the existing mindfulness-based CBT as it is already implicitly embedded.
The Pali word for mindfulness is “sati,” which is a noun for the verb “sarati”. It literally means “to remember.” In relation to the current concept of mindfulness, it is to remember to pay introspective, present-moment, non-judgmental, and wise attention to the processes streaming in the field of consciousness (e.g., thoughts, images, memories, impulses, emotions, bodily sensations, etc.); in other words, to remember to cultivate mindfulness as defined by Kabat-Zinn, “paying attention in a particular way, on purpose, in the present moment, and non-judgmentally.” This part of the definition of mindfulness (i.e., the act of remembering) is often neglected in the current mindfulness-based CBT. Though usually not emphasized in this way, it makes helpful sense to see it from this perspective. Extending from that, mindfulness in the context of MW would also include “remembering” to adhere to the aforementioned behavioral guidelines. In order to help us “remember,” Thich Nhat Hanh, a Vietnamese Zen master, in fact has creatively formulated the MW moral–behavioral guidelines as mindfulness training for the happiness of individuals, couples, families, and society (available at http://www.plumvillage.org/mindfulness-trainings/3-the-five-mindfulness-trainings.html).
In brief, the moral–behavioral practices of MW can enhance the practice of mindfulness as currently understood in mindfulness-based CBT. Mindfulness practice with the less emphasized memory construct and Right View in turn would strengthen the behavioral practices of MW. Behavioral practices themselves as virtues may transform negative AT leading to positive mental states. Therefore, it is helpful to be “mindful” of (remember) the potential role of MW moral-based guidelines for integration in the current mindfulness-based CBT (see Table 1).
Right Speech, Action, and Livelihood of the MW (i.e., Sila or morality training) are collectively and commonly represented by the base of a pagoda (see Fig. 2). As can be seen, it forms the foundation for the other five cognitive–behavioral or mental cultivation guidelines of MW. The first three cognitive–behavioral guidelines—Right Effort, Concentration, and Mindfulness (i.e., Samadhi or tranquility training)—are collectively represented by the body of a pagoda. The last two cognitive–behavioral guidelines are Right View and Thought (i.e., Panna or wisdom training) and are collectively represented by the peak of a pagoda (see Fig. 2). Here are the first three cognitive–affective guidelines of the MW.
Right Effort, Concentration, and Mindfulness
These are the first three cognitive–affective guidelines of the MW for the purpose of mental cultivation (bhāvanā), which is beyond mere morality-based behavioral modification. Bhāvanā is commonly translated as “meditation,” and this translation carries the potential danger of inducing an iatrogenic cognitive error.
The word “meditation” often conjures in many people the erroneous mental image of either an elderly, sage-like person sitting in a cross-legged position or an unkempt person on the verge of ego boundary disturbance or spiritual invasion. “Mental cultivation” is a better translation as bhāvanā actually refers to mental cultivation or training for transforming negative cognitive–affective states to positive cognitive–affective states. The various recommended mental cultivation exercises can be practiced by anyone, anywhere, anytime, and without any religious connotation.
Mental cultivation as a mental process has many components, and the first to be described here is Right Effort, which is fourfold: preventing negative cognitive–affective states from arising, helping negative cognitive–affective states that have arisen to subside, finding ways to generate positive cognitive–affective states that have not arisen, and nourishing positive cognitive–affective states that have already arisen. For many years, the CBT literature and many of its researchers and clinicians have seemed to focus primarily on challenging negative AT and core belief. This is only half of Right Effort. While it is achieving some good results, it may not be optimum.
Longmore and Worrell’s (2007) component analysis study has suggested that direct challenging of AT may not be needed in CBT. Maybe what is more helpful and needed is generating and nourishing positive cognitive–affective states instead of, or on top of, challenging negative AT. This is supported by some research in positive psychology (e.g., contentment or gratitude-based interventions for generating gratitude thoughts and feelings) which are associated with happiness and well-being (Emmons and McCullough 2003). Most of us are familiar with the use of the Automatic Thought Questionnaire (ATQ) for assessing the presence and believability of negative AT in depression (Hollon and Kendall 1980). Lesser known in clinical practice is the Automatic Thought Questionnaire-Positive which can be used for assessing and promoting positive AT (Ingram and Wisnicki 1988). As seen, fully utilizing the fourfold Right Effort which is established in the Buddhist teaching of MW is not strange or unreasonable at all.
Techniques that enhance positive cognitive–affective states should ideally be tailored to one’s cultural background to enhance their efficacy (e.g., protective chanting or mantra, melodious hymns, inspirational metaphors or stories, meaningful rituals, observing the sound of silence, regular prayers, invocation of spiritual powers, proximity with nature, association with positive and supportive people, etc.). These examples may be relatively foreign to some of those in the Western world, but they are rather natural for those accustomed to the Eastern way of life. It is “effective” and helpful to be mindful of adapting mindfulness-based CBT according to an individual’s psycho-spiritual and cultural needs.
Right Concentration is a one-pointed attention of the mind. It is the ability to keep the mind firmly anchored to an object (traditionally, 40 different objects of mental cultivation are recommended). This includes the practice of focus on breathing, visualizing objects or colors, and cultivating positive emotions such as friendliness, compassion, appreciative joy, and equanimity (Dhammananda 1987). Persistent training in such sustained attention can lead to a relaxation response and, further, to super-concentrated or absorption mental states known as jhanas. In such positive mental states, it is hypothesized by the MW that all gross negative cognitive–affective states will cease. Thus, from a MW perspective, negative AT and emotions can also be modified by this kind of Right Concentration attention control instead of the conventional techniques described in CBT such as relaxation training, Socratic questioning, and behavioral experiments. Mikulas (2010) has rightly suggested that the effectiveness of current mindfulness-based programs would be improved if more attention was given to Right Concentration training.
Though usually understood in the Buddhist context as a very deep and difficult-to-achieve form of sustained attention, Kwee and Taams (2006) have noted some similarities between the concepts of jhana with the more day-to-day concept of flow that is commonly described in positive psychology. Flow is a subjective, psychological state that occurs when an individual becomes so immersed in an occupation that one forgets everything except what one is doing. One who gets into flow often finds it so enjoyable that one will repeat the experience just because they want to for its own sake rather than as a means to another goal (Csikszentmihalyi 2002).
Flow has been associated with happiness, self-esteem, role satisfaction, work productivity, and satisfaction with life (Emerson 1998). Traditionally, flow is accessible through doing something sufficiently challenging that requires the full use of one’s skills. But a recent study has suggested that one can also access flow through mindfulness or moment-to-moment awareness (Wright et al. 2006). For practical reasons, it is proposed here that the passive way of Right Concentration attention training is through relaxation exercises (e.g., deep breathing, muscle relaxation, pleasant imagery), and the active way of it is through flow activities. In this way, more options of Right Concentration practice are available. Research in neuroscience using functional magnetic resonance has also demonstrated that Right Concentration attention training (also known as focus attention meditation) is associated with activation in multiple brain regions implicated in monitoring, engaging attention, and attention orientation. Most importantly, it is also associated with a reduction in amygdala activation which is related to emotional reactive behavior (Brefczynski-Lewis et al. 2007). Therefore, it is recommended that by extending Right Concentration practice (e.g., focus attention training with different meditation objects and cultivating flow) into the conventional techniques of CBT (see Table 1), it will be richer and able to benefit more patients.
Right Mindfulness is the one eighth of MW that has relatively gained a lot of attention in modern Western psychotherapy, in particular the third wave of behavioral treatments. To reiterate, the Pali word for mindfulness is “sati,” which means “to remember.” It is remembering to adhere to the behavioral guidelines of MW (Right Speech, Action, Livelihood), make the fourfold Right Efforts, cultivate Right Concentration, and dwell in Right Thought as well as Right View, the last two of which are comparable to positive AT and core beliefs in CBT.
The current mindfulness-based programs have the “remembering” memory construct embedded as the participants need to remember what is taught in the program and remind themselves to observe the present moment in a non-judgmental way. However, the memory construct is only to remember to observe and to be non-judgmental. It does not have the complete “remembering” as in the MW, which is remembering to pay introspective awareness and observe phenomena according to the teachings of “unsatisfactoriness,” “impermanence,” and “non-self,” which will be discussed under Right View. Nevertheless, we find it helpful to emphasize the current memory construct in mindfulness training. We emphasize to the participants the importance of (1) remembering what they have learned; (2) reminding themselves to practice the mindfulness skills; and (3) recalling their thoughts, feelings, bodily sensations, and their interactions with one another. “Mindfulness = 3R—Remembering, Reminding & Recalling” is one of our pedagogical approaches in our mindfulness training. In harmony with the MW, we are now introducing in our meta-mindfulness training the fourth R (Respect), i.e., respecting and accepting the realities of “unsatisfactoriness,” “impermanence,” and “non-self” (see Table 1). This emphasis on the memory construct of mindfulness adds clarity to the conceptualization of mindfulness, and it is also consistent with the literature on prospective memory. Since mindfulness has a lot to do with memory, we should explore the use of memory triggers to help patients cultivate all the positive behavior and cognitive–affective states of MW. This may include memory cards, environmental cues, screensavers, SMS messages, cell phone ring tones, mindfulness bells, and gathas, i.e., short verses which we can recite during our daily activities to help us dwell in mindfulness (Hahn 1990).
It is claimed in the MW that only when the mind has reached a super-concentrated state (Right Concentration) can Right Mindfulness, besides its role of remembering to “pay attention” act like an electron microscope to “pay wise attention” for achieving a complete Right View of human existence, i.e., spiritual enlightenment (Brahm 2007). Of course in a CBT context we do not expect nor want to fully “enlighten” patients. The primary aim here is to integrate the beneficial components of Buddhist philosophy into CBT so as to enrich the practices of CBT. We suggest that emphasizing more on relaxation and attention stability training (Right Concentration) can be a useful important step before working on identifying and challenging AT or core beliefs. This makes sense as a relaxed, stable, and sharper mind possibly has a greater capacity to catch a negative AT, like a more powerful computer antiviral program’s ability to detect and eradicate an elusive cyber virus. Experiments can be conducted to determine whether relaxation training (e.g., progressive muscle relaxation, deep breathing, pleasant imagery) and/or attention stability training (e.g., focused breathing, focusing on the feeling of compassion) would enhance one’s ability to identify and counter negative ATs (as in traditional CBT) and engage in cognitive defusion techniques (as in ACT).
In practice, Right Effort, Concentration, and Mindfulness are interrelated forms of attention training. They are practiced together and act simultaneously like three-in-one instant coffee to produce positive cognitive–affective states. Illustrating with a simile, the three-in-one mental cultivation process is like repeatedly restraining a monkey to a tree with a rope. The monkey represents our restless mind. Right Mindfulness is the mental watchdog that remembers to remind us whenever the monkey mind is running away. Right Effort is responsible for repeatedly pulling the monkey back to the tree with a rope. After some time, the monkey will give up its worthless striving and just rest around the tree. Similarly, the mind will settle down and achieve a state of tranquility (Right Concentration). Some of the current conceptualizations of mindfulness are as various forms of attention training/control (e.g., sustained/focused attention, shift/selective attention, detached attention; Dorjee 2010; Shapiro et al. 2006; Wells 2005). These attention control trainings invariably involve Right Mindfulness, Right Effort, and Right Concentration, but have been collectively labeled as and reduced to “mindfulness.” Meta-mindfulness and the above simile allow us to see truths from different perspectives. A recent RCT has shown that mindfulness meditation significantly improves sustained attention as compared with progressive muscle relaxation and waitlisted list control (Semple 2010). The mindfulness meditation method used in the study is the Herbert Benson’s relaxation response method, which again basically involves Right Mindfulness, Right Effort, and Right Concentration strategies.
Some may be confused over the meaning of mindfulness and have the opinion that the current concept of mindfulness training seems closer to just “right concentration” as mindfulness is a lot about attention training. As explained earlier, there is some truth in this, yet it is not the full spectrum of attention training as in MW which includes Right Mindfulness, Right Effort, Right Concentration, Right Thought, and Right View. It is not even the full spectrum of concentration/attention training of Right Concentration which commonly includes cultivating positive emotions such as appreciative joy (mudita), i.e., rejoicing in the good things in life. In short, mindfulness is “remembering,” “paying wise attention,” and “right concentration.” Mindfulness is meta-mindfulness and cannot be reduced especially in practice to just “memory” or any other construct. The eight spokes of a wheel used to represent the MW need to be present to turn the wheel of effective therapy, and Right Mindfulness is only one of them. Hence, meta-mindfulness is the way to go about for a more meaningful and practical way of understanding mindfulness.
It is interesting to note that in the MW, the already mentioned three mental cultivation guidelines are given utmost emphasis as a prerequisite for Right Thought and View, the equivalent to positive AT and core belief in CBT. As touched on earlier under Right Concentration, there are numerous types of mental cultivation techniques catering for people with different personalities and problems. Examples of very popular MW mental cultivation techniques are those based on the Four Immeasurable Loves or Pure Abodes (Brahmaviharās). These techniques can be skillfully tailored to effectively cultivate friendliness (metta), compassion (karuna), appreciative joy (mudita), and equanimity (upekkha), all positive cognitive–affective states that are potentially effective antidotes for anxiety and depressive states (see Table 1). Coincidentally, these are also some of the 24 characteristic strengths associated with psychological well-being as described in positive psychology (Peterson and Seligman 2004). Neuroscience research has also demonstrated that loving-kindness and compassion meditation is associated with positive alteration in the structure and functioning of the brain (Lutz et al. 2004). Compassion meditation is also associated with reduction in stress-induced immune and behavioral response (Pace et al. 2009). More research should be considered to determine how these various generic techniques (one does not have to become a Buddhist or have faith in Buddha to practice these techniques) can be integrated in a “meta-mindfulness-based” CBT approach.
Right View and Thoughts
The last two cognitive–affective guidelines of the MW are Right Thought and View. Right Thought is like positive AT and Right View is like positive core belief in CBT (this may be oversimplistic, but it is a helpful way of integrating the CBT and MW model of cognition). As the eight guidelines in the MW are interconnected and circular in their relationship, these two cognitive–affective guidelines are the initial and also end point of MW. For example, we need to have some positive thoughts and views on MW before deciding to walk the MW. Similarly, we need to have some knowledge of CBT before deciding to engage in CBT. As we walk along the MW, we will naturally discover more right thoughts and views that will eventually culminate into perfect Right Thought and View, also known as Enlightenment in the MW.
Right Thought in the MW mainly refers to thoughts of compassion, generosity, and service. Right Effort as described earlier is making the fourfold effort to suffuse the mind with such positive AT to condition positive emotions. Of course, we need Right Mindfulness to remind us and Right Concentration to focus on the Right Thought. And these mental faculties need to be supported by the moral–behavioral guidelines (i.e., Right Speech, Action, and Livelihood) before they can gain sufficient momentum and culminate into Right Thought and View. This is how the various interrelated guidelines of MW work harmoniously and synergistically. Similarly, with further integration of the above meta-mindfulness concepts in CBT, we suggest that the practice of CBT can be improved to benefit people suffering from psychological problems and disorders.
Right View refers to the investigating, understanding, and acceptance of the three omnipresent and interrelated realities of existence: “unsatisfactoriness” (dukkha), “impermanence” (anicca), and “non-self” (anatta). From a CBT perspective, it basically means to investigate, cultivate, and realize the positive core beliefs that happiness is proportionate to the degree of contentment, ability to embrace change, and selflessness in life. Not surprisingly, contentment or gratitude-based and service or kindness-based interventions have been shown to be effective for generating happiness and well-being (Burton and King 2004; Emmons and McCullough 2003; Lyubomirsky et al. 2005; Parks and Seligman 2004).
Do “remember” that Right Mindfulness is making continuous attempts (Right Effort) to focus (Right Concentration) on such Right View. This can be skillfully integrated through mindful relaxation breathing and affirmation training (e.g., “Breathing in, I’m contented, breathing out, I’m peaceful. Breathing in, I embrace change, breathing out, change is growth. Breathing in, I’m selfless, breathing out, I’m full of joy”). Hence, the therapeutic attitudes in Right View can now be conditioned into breathing and embedded into life as “ultra-core beliefs.”
Right View in a way is the attitudinal aspect of mindfulness. Kabat-Zinn’s famous prototype definition of mindfulness is accompanied by seven mindful attitudes: non-judging, patience, beginner’s mind, trust, non-striving, acceptance, and letting go. Bishop’s definition of mindfulness also has an attitudinal component: curiosity, experiential openness, acceptance, and decentered perspective (Bishop et al. 2004). Camouflaged by semantic difference, these contemporary attitudes of mindfulness actually have some similarities with the attitudes in Right View. For example, “acceptance,” “letting go,” and “patience,” are closely related to embracing the realities of “impermanence” and “unsatisfactoriness.” Hence, it is rather sensible to explore Right View more thoroughly and consider adopting the attitudes in a secular manner (see Table 1), which has already been implicitly done to a certain extent in the current mindfulness-based CBT.
When it was first conceptualized, CBT focused mainly on negative thoughts or psychopathological symptoms like anxiety and depression. While this did help CBT to advance, recent knowledge in positive psychology has pointed out that this is inadequate. Thus mindfulness in CBT without incorporating Right Thought and Right View has again fallen into the same trap of earlier CBT conceptualizations, which have only negative conceptualizations of human mental disorders. Suggestions were made to integrate Cognitive-Behavioral Therapy and positive psychology (Karwoski et al. 2006). Mindfulness has also been proposed as the missing link between Cognitive-Behavioral Therapy and positive psychology (Hamilton et al. 2006). Therefore, we encourage the Western conceptualization of mindfulness to be expanded to meta-mindfulness that includes Right Thought and Right View. Hopefully, this will help achieve the full potential of mindfulness in CBT.
With these last two cognitive–affective guidelines, we now have the completed eight practice guidelines of MW. We postulate that this fully expanded concept of mindfulness into meta-mindfulness will enhance the theoretical and practical integration of MW with CBT and bring CBT to a whole new level of clinical practice, research, and training. Table 1 summarizes some of the intervention strategies based on meta-mindfulness. Table 2 summarizes some of the further experiments and research developments that can be done with meta-mindfulness. We hope that this expansion of mindfulness to meta-mindfulness will stimulate further discussion and debate to improve the theoretical development, practice, and training of CBT.
The concept of mindfulness has recently been successfully integrated into CBT as mindfulness-based CBT. But mindfulness is only one of the eight practice guidelines of MW in which the concept of mindfulness mainly originated. We suggest that mindfulness needs to be expanded to meta-mindfulness. Mindfulness’s full force as in the MW has great potential to be an effective variant of CBT. We hope that with this paper, a stronger wave of meta-mindfulness-based CBT will emerge and thus contribute to more advancement in the research, practice, and training of CBT for the benefit of the human race.
This is not referring to the “Middle Way” philosophy of Madhyamaka Buddhism.
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Phang, CK., Oei, T.P.S. From Mindfulness to Meta-mindfulness: Further Integration of Meta-mindfulness Concept and Strategies into Cognitive-Behavioral Therapy. Mindfulness 3, 104–116 (2012). https://doi.org/10.1007/s12671-011-0084-z
- Cognitive-Behavioral Therapy
- Middle way