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Mindfulness, Dharma, Mental Health & Science Part 2 of 2

The psychological and psychiatric realm is a messy realm of understanding suffering. Psychiatric conditions themselves are kind of messy. With other diseases, the focus is on pathophysiology. We don't talk about COVID-19 as "scratchy throat disease." We talk about it as a beta-coronavirus that attaches to specific receptors, causing inflammatory effects and a dysregulated immune response. In the psychiatric realm, we are talking more about signs and symptoms—"scratchy throat disease." It's too much to get into, but even just the category of something like depression hides an incredible amount of heterogeneity. That diagnostic category is not really sufficient, even though there's a lot of utility in having it.

This is a realm characterized by equifinality, meaning many paths lead to the same outcome. We can get to the same place through many different routes. It is also characterized by multifinality, where the same risk factor can lead to very different outcomes. We see that at the genetic level with pleiotropic effects, where the same genetic risk factors can manifest in very different ways. We also see a high degree of polygenicity; many genetic variations of very small effects become cumulatively meaningful in psychiatric conditions.

The causal map is quite complex. As an illustration, a twin study attempting to disentangle genetic and environmental risks for depression shows all the different pathways: childhood, early adolescence, late adolescence, adulthood, and the last year—all leading to the occurrence of a depressive episode. The lines don't just go from one thing to another; they go all over the place, amplifying or minimizing the effects of other risk factors. Monocausal theories, like "this one risk factor or trauma caused this," are always way more complicated. We could call that diagram Paṭiccasamuppāda^[1]—this is dependent origination. The complexity we see in these realms is a testament to the complexity of causality itself.

This has implications for how we think about treatment and healing. One of the effects is that it has moved us away from a purely DSM-based treatment approach. In psychiatric nosology, with its two hundred-odd clinical conditions, researchers have said the era of protocols for syndromes is over. The era of "if you have depression, you get this protocol" or "if you have generalized anxiety disorder, you get this," is still true to some extent, and that's not a bad thing. But the focus is moving towards core psychopathological processes, understanding the mechanisms that promote or maintain psychiatric distress. It's a movement away from strictly evidence-based treatments to what one of my teachers called "empirically supported principles of change." It's less about trademarked approaches like DBT and more about what is actually shared across psychosocial treatments.

The Dharma as a "Dirty Drug"

Some drugs are known for being highly selective. For instance, an SSRI (Selective Serotonin Reuptake Inhibitor) is supposed to hit specific receptors and not others. No drug is perfectly selective, but some, like Celexa, are highly selective. Then there are drugs that are sometimes called "dirty drugs," hitting a wide range of different receptor systems. I would say the dharma is a dirty drug. Just to use that as a metaphor, who knows what it does at the level of the brain—that's being investigated—but figuratively, the dharma has elements of many different therapeutic approaches. Its mechanism of action is multiple. It has overlap with attentional training, cognitive therapy, deep overlap with exposure therapy, and it evokes existential therapy in some really important ways.

Mindfulness as Attentional Training

Disrupted attention is a unifying construct in psychology, disrupted across a wide range of psychiatric conditions in different ways. In addiction, there is an attentional bias to drug cues. In obsessive-compulsive disorder and post-traumatic stress, there is often intrusive, unbidden thinking. In generalized anxiety disorder, we are entangled in worry, and attention moves into the realm of an amorphous sense of threat. In depression, there are concentration problems, memory effects, over-general autobiographical recall, and an attentional bias to negative information. Attention deficit hyperactivity disorder has "attention" right there in the diagnostic label. Even in subclinical distress, our attention has a pinball effect—moving from past, to future, to unpleasantness in the body, springing us into narratives and autobiographical storytelling. Attention is simply not stabilized in distress.

It may be that this attentional disruption is epiphenomenal, just the steam coming off the engine of psychiatric illness. But it may be worth exploring attentional training. As we learn to stabilize attention, to bring some measure of Samādhi^[2], of tranquilizing the inner field of experience, maybe this is useful for forms of distress.

Mindfulness as Cognitive Therapy

Dharma is a cognitive therapy. A lot of what the Buddha does is tell us how to think. This is not a popular trope; we often try to hide the rhetorical gestures of the dharma behind the claims that it's self-evident—"just see for yourself," ehipassiko^[3]. But we are being told what to think a lot. Right view is the foundation. With wrong view follows wrong intention, wrong speech, wrong action, and wrong mindfulness. With right view, we are told, "Dukkha^[4] is like this." We are invited into ways of understanding that reduce suffering. A lot of dharma teaching is an invitation to new ways of construing experience. In clinical literature, you would call it cognitive reappraisal.

Consider the contrast between mindfulness-based cognitive therapy (MBCT) and traditional cognitive therapy. MBCT, largely derivative from MBSR, was originally designed to prevent relapse into depression. In remitted cases, MBCT is an attempt to become mindful of early depressogenic thinking. We minimize the threat of that thinking by knowing thought as thought. It is not disputing the contents of the thought. If a thought says, "This day is going terribly, you're a failure," you don't challenge the content by saying, "Well, it wasn't that bad, you've done this before." You just recognize, "I am hearing a sound in my own head telling me this is going badly." That is thought as thought.

Despite this contrast, there's a lot of overlap between mindfulness-based approaches and cognitive therapy. We are invited into a system of beliefs where dukkha can be redeemed, where goodness has force, and where awareness has potency. We reframe pleasant and unpleasant, and over the course of practice, we come to construe the entirety of our life in light of the dharma. We understand our suffering, our longings, and our goodness in light of these teachings.

The benefits we see early in practice during short intervention studies are largely cognitive. The idea that we're getting profound, samadhi-ish benefits at week eight is not tenable for most people; that has to mature over much longer spans of time. So what accounts for the robust demonstration of benefits in short interventions? A lot of it is the destigmatization of dukkha. We start to feel unashamed of our pain, and we normalize the intensity of the human condition. The secular distinction that mindfulness is merely a technique and not a view is not viable. We really cannot separate the view from the technique; there is no viewless technique.

Mindfulness as Exposure Therapy

Exposure therapy is a key mechanism in a range of different therapeutic approaches. A good proportion of our distress is maintained by experiential avoidance—the unwillingness to encounter and be present for private events, and our efforts to alter their frequency or the contexts that occasion them. This is prominent in anxiety, where our avoidance of the feared object starts to narrow our life until it feels claustrophobic. Anxiety thrives on avoidance.

Michelle Craske, a major exposure therapy researcher, argues for moving away from immediate fear reduction and towards fear toleration as the primary goal of exposure therapy. Fear toleration sounds familiar—it's the pāramī^[5] of patience, of equanimity, of allowing and approaching. In the therapeutic realm, there is usually an attempt at systematic desensitization. If someone has PTSD from a car accident, the first step might be drawing a car, then sitting in a parked car, then riding in a parking lot, slowly draining the affective charge and graduating to driving on the highway at rush hour. That is systematic exposure therapy.

In the dharma world, mindfulness practice is unsystematic exposure therapy. Anything that can disrupt your peace will. We don't put that on the retreat flyers: "Insight retreat: anything that can disrupt your peace will. Please join us!" But that is real. It is our good fortune that our pain, clinging, greed, hate, and delusion re-arise. If we sit and practice enough, they will. The idea in exposure therapy is to get the right dose of subjective distress. Too little, we don't learn. Too much, we're flooded and we don't learn. So we play at the edge of our own threshold and tolerance. In our dharma practice, we are desensitizing to the impelling forces of clinging. This is the purification side of practice, the path of purification. In clinical language, that is exposure therapy for everything.

We don't always see the habituation in an explicit way. We just wake up someday and recognize, "I don't suffer in that way anymore, and I don't know when it went, but I feel freer." Dharma practice operates with an approach orientation, approaching that which might be avoided. Training in attention and in love makes the approach especially deep. How do I approach the loops of pain in me? The dharma helps us get close. We pour awareness into the circuits of avoidance and entanglement, moving against the tide of avoidance. Love, care, willingness, and surrender are the deepest forms of approach.

This is the exposure therapy side of practice. We also have the tranquilizing side, meant to make the exposure bearable. Dharma practice is a dialectic between tranquility and exposure. There is a risk that one just gets wedded to the tranquilizing side and enlists it as a mechanism of avoidance itself. People with a natural predilection for quiet might use it to hang out in avoidance, meaning the encounter with their own dukkha is not made. Their core behavioral patterns are left untransformed. If we're sincere, we wise up to this sooner or later.

Existential Therapy and Mortality Salience

The dharma has elements of existential therapy. Existential therapy, which I associate a lot with Irvin Yalom^[6], hypothesizes that the failure to meet the existential challenges of any human life adequately leads to psychiatric symptoms. These challenges include death, responsibility, and our solitude—we are connected in a million ways, yet born alone, die alone, and live alone in very important ways. The dharma began with these very challenges: aging, sickness, and death. If it is true that everything will be lost, what is to be done? That is the animating question of the dharma.

There is evidence that meditation and Buddhism reduce our defensive responses to thoughts of death, known as mortality salience. When mortality is made salient in a research subject, things often happen that are not good: they become more territorial, show more in-group favoritism, and become more rigid in their ideology. But mortality salience can cut both ways—groundlessness can make us hate, or it can make us love. Fear in our politics is mobilized to manipulate people's behavior because we are unconscious and easily manipulated. We have to know our inner life to make those levers less accessible to deluded powers. We must come into relationship with our own mortality.

Studies on terror management theory show that defensive responses consistently found in the absence of meditation were not found after meditation. Higher levels of trait mindfulness are associated with lower levels of defensiveness in response to mortality salience. The notion is that we cling to our ideology and views as a form of symbolic immortality. We cling to a sense of what lasts beyond us. We want to be conscious of how we construe this and not use it as a defense against the truth of our existential condition. It is possible for our hearts to be softened rather than hardened by anicca^[7], by groundlessness and uncertainty.

The dharma operates in many ways through many different mechanisms. As teachers, we often highlight some mechanisms rather than others. Some of the most popular approaches zone in on one mechanism, boiling it down to something simple. There is rhetorical power in that, but also naivete. The dharma works in so many different ways, and we have to talk about it in nuanced ways that sometimes sound paradoxical. It is a skillful means.

The Phenomenology of Distress vs. Mindfulness

The interest in mindfulness in the therapeutic world is less about the strength of clinical trials and more about how mindfulness describes a state that is nearly diametrically opposed to psychiatric distress.

What are the characteristics of distress? Thoughts become absorbing and imposing, feeling as real as a piece of furniture. Rumination is a trans-diagnostic risk factor that masquerades as existential questions, giving thoughts a density and weightiness. In distress, the space of experience narrows into a kind of claustrophobia. The attentional field and peripheral vision literally narrow, utterly lacking the vast expansiveness of a "big sky" awareness. Attention becomes fragmented, pinging all over. There are alterations in physiological arousal—sometimes hypo-aroused, numbed out, and dissociative, but often hyper-aroused. There is experiential avoidance and compromises in distress tolerance. We are in deep contention, fighting with ourselves. Pain is personalized and viewed as a moral failing; my depression becomes a commentary on the defectiveness of my own being. There is an unhelpful rigidity in our predictive models and schemas, particularly in our model of self. This model becomes impervious to disconfirming information. Our reasoning becomes motivated, erring on the side of confirming existing models rather than opening to the unknown.

Mindfulness moves us almost directly against each of these characteristics. There is a reduction in cognitive fusion; we establish meta-cognitive awareness and are no longer fused with the content of thought. We wake up from the daydream, realizing we were living in the bubble of discursive thought. Mindfulness breaks this identification through de-reification, appreciating the anicca and dukkha quality of thought itself. Thoughts that had been imposing become just another empty phenomenon.

As the story goes with Joseph Goldstein and a yogi on a three-month retreat. She came in having a spasm of self-hatred, saying, "This is wrong with me, and even the chipmunks hate me!" Joseph responded, "Even the chipmunks hate me, and the sky is blue." Both thoughts are made of precisely the same stuff. It juxtaposes the most innocent, uncharged statement with the most charged spasm of self-hatred. Their currency is identical: empty de-reification.

Mindfulness is conjoined with equanimity. If we attend to phenomena without equanimity, attention will amplify them for better or worse. We've all had moments in meditation where we notice everything and hate everything—there is present-moment awareness, but zero equanimity, resulting in a dukkha-filled state. Equanimity is the practice of distress tolerance. We approach that which is avoided, exercising exposure-based learning mechanisms, learning not to fight with ourselves at any level.

A moment of mindfulness is almost by definition a non-moralistic moment. We drain the moralism from our emotional life. We recognize causes and conditions. I am not angry, sad, or lonely because of my own moral failing; I am sad because of everything ever—that's Paṭiccasamuppāda. So much of what we do in dharma is destigmatizing pain.

A moment of mindfulness is also a hypo-egoic state. We train not to take refuge in ideas of who we are, giving up hope of arriving at a permanent identity. The practice deconstructs the sense of self, accessing states where the self is thinned out, spacious, and impersonal. The underbelly of sakkāya-diṭṭhi^[8] (identity view) is shame. Claiming the territory of "I am-ness" creates a fertile ground for shame. As the sense of self becomes more fluid, flexible, and open, the ego becomes healthier. We keep going until we become less enchanted by the endless shell game of the egoic charade. We realize we are never going to land in a self that feels like home, and that changes who we are in relation to others and ourselves.

Because a moment of mindfulness is diametrically opposed to the hallmarks of distress, mental health professionals cannot help but be curious about what the Buddha articulated here. Mindfulness is multifaceted, but in some visions of Abhidharma, mindfulness is almost tantamount to freedom—free of defilement. This is a key reason for the immense interest in the mental health world.

Q&A

Question: There is a difference between being with the dharma for therapeutic value versus being in other types of therapy, where there is an interaction with another person. Dharma practice is pretty self-regulating; we sit there for long periods talking to ourselves. Doesn't that interaction have the potential and danger of becoming delusional and lazy? Also, in the East, Buddhism is a ubiquitous cultural phenomenon with a common understanding of the inner life, which we don't have as much in the West. How do we avoid becoming deluded and lazy in our practice?

Matthew Brensilver: Every practice and teaching can be used or misused. It is possible to misuse mindfulness as a way of recapitulating greed, hate, and delusion, rationalizing our own defilements in the name of the dharma. Two things stop us from doing that: our own sincerity and the mirror of other people.

This path requires investigation. We have to get really curious about how our practice might be functioning to reinforce our own delusion, because we don't just check our habits at the door. The way we practice is the way we do everything else. Sometimes practice is recruited as a way of insulating ourselves. Teachers and the sangha can help us detect that, but our own sincerity is vital. We must be willing to look at our own hypocrisy and the gap between our public and private selves. When I teach, I hear myself and have to be accountable to those words. If I feel a gap between what I say and how I am in my private life, that is unsettling to me.

A friend of mine says, "If we want to know, we will. And if we don't, we won't." Are we committed to just seeing? If I feel like my discoveries are the deepest commentary on who I am, it short-circuits the investigation. Not all self-knowledge is good news. I just want to see it, even if it causes shudders of shame, because it is of the nature of not-self. Delusion is endless; we can never stop asking if we're deluded because until it feels like a delusion, it feels like the truth. We will never have a 360-degree view of ourselves, which is why we need others to help point out our blind spots.

Question: I've worked as a nurse for over thirty years, largely with the homeless in downtown San Francisco. When people come into triage babbling to themselves, a quick remedy I use is having them put a hand on their center chest and just breathe. I spent the week watching the ceremonies surrounding Thich Nhat Hanh's passing and was reintroduced to his simple practices. He continually talked about bringing your center to your breath—the refuge in your body—during moments of severe dukkha. I use that and it works well as a quick fix, providing parasympathetic stimulation and mindfulness. I just wanted to share that and thank you for your presentation.

Matthew Brensilver: Thank you. On the one hand, it sounds simple, almost like a gimmick, but it's actually not. Hearing the way you describe it, I can feel your practice in it. It's tied into a whole raft of wisdom and compassion in you. That's not trivial for you to say that to a homeless person with schizophrenia. I got the hit of it just hearing you; I could feel it in my own heart.

You also offered a continued rumination for all of us about whether we are just cherry-picking the good parts of Buddhism. Buddhism developed for hundreds of years in India before moving to China. Translators like Kumārajīva translated it into Chinese, and the Chinese already had their own philosophical systems—Daoist and Confucian—so they used their own words. Similarly, we have our own therapeutic history with psychology, and we can take these beautiful practices and weave them into our understanding. There are huge streams of this wandering around the West now—some simplistic, others extremely beautiful.

Question: You mentioned renunciation and sīla (ethics) as approaches contrasting with secular mindfulness. I find many translations are lost on me. I didn't understand what citta^[9] was until I compared it to polyvagal theory. Retreats focused on the brahmavihārās used to send me straight to hell because I struggled with the near and far enemies. But when Oren Jay Sofer described the brahmavihārās as being there to protect me, it turned me 180 degrees. Renunciation is something I haven't touched because I don't understand it. Also, I heard you once give a definition of wisdom that I keep with me: you said acts or words of wisdom are wise when they set people free and create liberation. That is now my guide.

Matthew Brensilver: Thank you for sharing that. As a principle, we have to have working definitions of things, but we shouldn't get too caught up in them. Anyone who wants to definitively define the mind or citta is guilty of grandiose thinking. We get a sense of it and work our way into deeper, more nuanced understandings. We have to define mindfulness to start practicing, but truly understanding what mindfulness is is the fruition of practice, not the beginning point.

Regarding renunciation, it is often underemphasized in secular articulations of practice, yet it's at the heart of the Buddhist lineage—the Buddha was a monk. While ethics (sīla) are shared across secular and Buddhist lines, renunciation is often minimized in the secular realm. It can sometimes feel like we're just grafting mindfulness onto our existing lives, which is not the true gesture of the dharma heart.

Question: I want to pose a framework regarding the intersection of the dharma and the mental health profession. Is there a way that holding both together might help in arenas where one or the other is lacking? In the mental health profession, there is a lot of lack. In the dharma, the particular area I'm thinking of is trauma. In working through trauma, I often read in dharma books that intensive practice is contraindicated for people with severe childhood trauma, but I couldn't find much else that helped me. I also found problems in the mental health profession's handling of this. By having both, I patched something together that I don't think I would have gotten solely from either. Do you have any thoughts on this?

Matthew Brensilver: I appreciate what you're saying, and I do think the two traditions can inform each other. We are seeing a more psychotherapeutized dharma being articulated, which has both pros and cons, but certainly some important benefits. The dharma can feed into mental health, supporting the welfare of clinicians and deepening the interventions they deliver. There is a lot of cross-fertilization.

I'm glad you found your own way by grafting together different approaches. In the realm of trauma, I am very enthusiastic about the potential of dharma practice. We don't want to underestimate our pain, nor do we want to underestimate our resilience and the capacity of our own heart.

Thank you all for your understanding and attention. It was nice to mix it up around all of this. If I trespassed in any way on your heart this morning, I ask for your understanding. See you on the dharma trail.