Dharma and Distress: Buddhist Teachings that Support the Psychological Principles in a Mindfulness Program

Dharma and Distress: Buddhist Teachings that Support the Psychological Principles in a Mindfulness Program

Lynette M. Monteiro

10.1 Introduction

This chapter explores the Buddhist teachings that inform and underpin the themes contained in mindfulness-based interventions (MBIs) using a mindfulness program as a template protocol. It begins with a Buddhist perspective of the general themes of a mindfulness program: self-concept, emotional regulation, and the causes of stress. Following sections unpack the contributions of the two primary suttas from the Pali Canon, the Satipatthana and Anapanasati Suttas (Analayo 2003; Bodhi 2005; Buddhadasa 1976; Goldstein 2013; Gunaratana 2012; Hanh 2006, 2009a; Silananda 2002) to the curriculum of secular mindfulness programs. While these two suttas are the primary supports of mindfulness programs, there are also subtle themes informed by Buddhist canonical teachings that are worthy of note. Theravada Suttas that elucidate the themes of emotions, interpersonal contact, ethics, and community are also explored (Germer 2009; Hanh 2007, 2011; Harvey 2000; Keown 2005; Neff 2011; Salzberg 2002). The contribution of the Mahayana teachings to mindfulness programs is also important to the subtle themes of a mindfulness program. Concepts of identity are explored through Zen stories and koans and the ox-herding pictures serve as a guide for the spiritual journey that is at the heart of any mindfulness program (Soeng 2006).

10.1.1 Themes and Variations of Mindfulness

The cultivation of mindfulness in Buddhist practice is a central component in the transformation of suffering or dukkha. The definition of mindfulness (sati) however is diverse reflecting the many different Buddhisms and their attendant

philosophy and psychology (Williams and Kabat-Zinn 2013). Common to all perspectives of Buddhist practice is mindfulness as right mindfulness, rich in meaning and one of the “folds” in the Eightfold Path. One definition of mindfulness is a mental quality that recalls the path by which dukkha occurs and can be caused to cease (Goldstein 2013; Thanissaro 2012). It is this role in the process of cessation of the cause of dukkha that gives mindfulness its potency and makes it a focus of Buddhist practice.

Because of its association with the cessation of suffering, mindfulness has become an important component in the treatment of illness in secular and clinical settings. Current secular applications of mindfulness share with its Buddhist origins the intention of transforming dukkha and teach its practice in nonclinical programs for wellness and as clinical psychotherapeutic interventions conducted in individual or group sessions (Baer 2005; Germer et al. 2013; Kabat-Zinn 2003). Although the intent of current mindfulness approaches is consistent with Buddhist practices (Monteiro et al. 2014), the manner in which Buddhist teachings infuse and support the secular conceptualization and delivery of mindfulness practice is not always made clear or explicit. This clarification plays an important part in understanding the complicated and easily misunderstood concept that Westernized mindfulness has become (Grossman and Van Dam 2011).

Understanding the links between Buddhist teachings and its secular applications is crucial in the delivery of mindfulness programs and in the training of professionals delivering such programs for three reasons. First, it ensures that wisdom and virtue are conveyed as integral to mindfulness in its secular application. Second, it creates a framework within which mindfulness can be communicated skillfully. Third, it provides a compass to navigate through the process and progress of the participants’ practice. Moreover, without a clear understanding that the path of transformation is through the cultivation of wisdom, virtue, and meditation, mindfulness approaches run the risk of becoming a superficially applied method. The need for understanding the complex Buddhist principles and models of distress or dukkha has been voiced in many clinical and Buddhist publications (Maex 2011; Sharf 2013; Williams and Kabat-Zinn 2013). Questions posed have ranged from assessing if secular and clinical views of mindfulness are consistent with Buddhist principles to the necessity for reappropriating mindfulness as a specifically Buddhist model of developing well-being (Purser and Loy 2013; Titmuss 2013). While the debate continues mostly unresolved, there are few discussions that examine the Buddhist teachings that underpin secular mindfulness treatment programs. This understanding is crucial if secular mindfulness programs are to convey the components of mindfulness in a way that enhances the potential for well-being.

Buddhist teachings of mindfulness practice are an elegant and complex process. The path that leads to the alleviation of suffering is direct (Analayo 2003) and drills down into the roots of the causes of suffering. The intention of this examination and diligent uprooting of the causes of suffering is to cultivate wisdom and compassion for self and others. That is, the path of transformation is not only to develop mindfulness so the suffering ends but also to nurture the mind of love or bodhicitta (Gethin 1992/2001). In order to develop a practice that encompasses these two factors of transformation, mindfulness programs are enriched when approached from an understanding of the key teachings of Buddhism.

Before beginning to examine the relevance of these important teachings to mindfulness treatment programs, two points are necessary to hold in mind. First, the landscape of Buddhism, its philosophy, and psychology is vast and complicated. The intent in this chapter is not to engage in the intricacies of establishing authority or authenticity of secular and clinical forms of mindfulness, but rather to examine the Buddhist teachings that underlie the principles of contemporary mindfulness. Second, the landscape of Westernized mindfulness is still in the process of being sculpted; definitions, mechanisms, and suitability to clinical populations are slowly being clarified (Baer 2003, 2011, 2005). Nevertheless, there are psychological themes that can be held up and viewed through the lens of Buddhist principles and psychology so that this growing edge of Buddhism and Western psychology can be better understood. It is useful therefore to establish first the composition of current clinical mindfulness programs and the core principles of Buddhist thought on the generation of psychological distress. MBIs have developed over the past 35 years as the sine qua non of psychological treatments. While mindfulness-based stress reduction (MBSR), developed by Kabat-Zinn (2011, 2013) is accepted as the icon of stress reduction MBIs, many programs have been developed that differ in content and intent (Cayoun 2011; Monteiro et al. 2010; Segal et al. 2012). However, there are sufficient commonalities to allow a general discussion of their makeup. Although MBSR began with the influence of both Zen and vipassanna teachings, mention of Buddhism was avoided and its design strived to reflect the Dharma without Buddhist- or New Age-sounding terms that would distract from its intention (Kabat-Zinn 2003, 2011). Nevertheless, the definition of mindfulness offered by Kabat-Zinn has created a level of confusion and contradiction when assessed by Buddhist criteria (Davis and Thompson 2013; Dunne 2011). One rationale for downplaying Buddhist terminology in MBSR was to make the programs more accessible to non-Buddhists and to limit any negative reactions to being perceived as based in a religious framework (Kabat-Zinn 2011; Langer 1990). Another rationale was that the essence of Buddhist philosophy was universal and did not require explicit mention; this was also applied to the mention of ethics (virtue practices or sila), which was assumed to be embedded in the content and emerged from practice naturally. This latter deletion of a primary principle of Buddhist thought has been the focus of much criticism and debate in the mindfulness communities (Titmuss 2013).

Several Buddhist practitioners have addressed the difficulties with the way mindfulness is understood in Buddhism and will not be addressed here (see Williams and Kabat-Zinn (2013) for detailed discussion on Buddhist definitions of mindfulness). However, in order to fully appreciate the interconnection of Buddhist psychology and the clinical use of mindfulness principles, both the formulation of a mindfulness program and the commonly accepted Buddhist principles that support it are set out below.

10.1.2 Clinical Applications of Mindfulness Interventions

MBIs were developed to address mental health issues from a different standpoint than earlier historic might read smoother therapeutic approaches. Where before the focus was on what ailed the individual, MBIs shifted the attention to what was healthy. Through various meditative practices and interchanges with the facilitator of the program (inquiries) the healthy aspects of an individual’s life are made accessible through a direct experience of that life. The approach drew from Buddhist principles such as impermanence, absence of a fixed, defined self, and the reality that suffering is a common experience. It developed awareness of these principles through technical skills such as various forms of meditations and yoga.

The secular and clinical application of mindfulness in Western psychology is attributed to both Langer (1990) and Kabat-Zinn (2013). Langer’s mindfulness skills and interventions are based on a cognitive model that focuses on problem solving, developing creative perspective taking, and other outcome-focused procedures. The model of mindfulness developed by Kabat-Zinn and others relates to the experience that is unfolding for an individual. Initially called the stress-reduction and relaxation program (SRRP), the intervention developed to be the now-widely known model of mindfulness called MBSR. The prolific use of MBSR has resulted in the acronym taking on iconic proportions such that a program employing mindfulness and meditation is typically associated with it. The clinical territory of mindfulness interventions, however, is widespread encompassing far more than stress reactions to physical and mental challenges (Eberth and Sedlmeier 2012; Fjorback et al. 2011). Its application has expanded to the treatment of numerous mental health issues such as depression, anxiety, addictions, and eating disorders to name a few. Various clinical treatment models have been integrated into the development of MBIs. Cognitive behavioral therapy (CBT) has fostered mindfulness-based cognitive therapy (MBCT; Segal et al. 2012) and mindfulness-integrated cognitive behavioral therapy (MiCBT; Cayoun 2011). Addiction models have fostered mindfulness-based relapse prevention (MBRP; Cowen et al. 2010). These have been beneficial integrations of traditional clinical approaches with mindfulness that enhance both protocols and resulting in a paradigm shift for the former and a new venue for application for the latter.

Mindfulness interventions are delivered in both individual and group formats. As an intervention for individuals, mindfulness can inform the therapist’s approach to addressing psychological issues (Shapiro and Carlson 2009a); that is, it has incorporated into a preexisting therapeutic model the concepts of mindfulness such as impermanence, nonself and other Buddhist principles. Therapy can also be mindfulness based in that it reflects the principles of mindfulness and includes many of the practices such as meditation.

The more familiar format of MBIs is as a group program where the basic format tends to be consistent across applications (Cullen 2011; Kabat-Zinn 2013). It is composed of 2–2½-h classes offered in an 8–10 week session with an all-day meditation retreat about halfway through the course. Although this is a typical format, there are several adaptations in the length of each class or the overall number of weeks; this is typically dictated by the needs and capacity of the population seeking treatment. For example, in working with groups diagnosed with schizophrenia, Jacobs et al. (2014) have discussed how modifications may be necessary to be consistent with the individuals’ ability to sit in silence for meditation. Other adaptations were explored by (Hickman et al. 2012) and summarized by Dobkin et al. (2013).

The specific content of an MBI varies along a continuum of experiential to cognitive approaches. MBSR and its variants tend to rely on experiential styles of interacting with the inquiry process leaning more towards shaving away intellectualization of our experience and creating a space in which sensations and emotions can be directly felt. Other programs balance more didactic styles with the experiential processing to offer both understanding of the disorder as well as experiential connection with the emotions arising at the moment. Although all programs have a curriculum, programs such as MBCT and MiCBT lend themselves to a more manualized approach.

The effectiveness of mindfulness interventions has been well established although the exact mechanisms by which it is achieved have yet to be elucidated fully (Coffey et al. 2010; Grabovac et al. 2011; Shapiro and Carlson 2009b). For example, MBCT has been demonstrated equivalent or superior to medication or treatment as usual (TAU) for depression (Kuyken et al. 2008; Piet and Hougaard 2011; Teasdale et al. 2000). Reduction in symptoms of anxiety disorders have been reported (Vøllestad et al. 2011). Pain and addiction symptoms have also been found to be responsive to mindfulness protocols (Cusens et al. 2010; Kabat-Zinn et al. 1987). Follow-up studies show maintenance of practice is an important part of sustained well-being (Bowen and Kurz 2012; Carmody and Baer 2008). While clinical uses of mindfulness tend to focus on diagnosed psychological issues, secular applications target more generic issues such as generalized stress or a desire to improve the quality of life. Each mindfulness program will differ in specific content as an interactive and organic unfolding as the relationship between facilitator and participants drives it. However, the general principles of most programs follow the map of the original MBSR program and typically two central Buddhist suttas are referenced in these programs: the Anapanasati and the Mahasatipatthana (Cullen 2011). A number of other teachings from the Theravada and Mahayana/Zen traditions implicitly support themes in an MBI however have not been previously explored. They are included here as potentially fruitful sources for future examination.

10.1.3 The Dharma of Psychological Distress

Buddhism provides a twofold understanding of the universe: cosmological and psychological (Gethin 1998). Of interest to the discussion of mindfulness is the psychological model of the realities faced by all beings. The central tenet of those realities is that all experiences result in dukkha (Harvey 2013c). Current interpretations of this complex term reflect a sense of dissatisfaction with or of being off-balance in our life; for ease, the Pali term dukkha will be used throughout. The Buddha was emphatic that he taught only two things: the understanding of dukkha and its cessation (Bodhi 2008; Gethin 1998; Hanh 1998). These two teachings are contained in the four noble truths or true realities, which point to the realities that arise in a human life and form the base of the Buddhist perspective on distress. Conventionally referred to as a diagnostic protocol for determining suffering, its cause, the prognosis, and treatment, the four realities of all beings are elegant in their simplicity yet complex in their ministration. They begin with the first reality, the acknowledgment that dukkha exists. This suffering arises by three means: as an inevitable part of life, as a resistance to the reality that things change and often not to our liking, or as an outcome of learned and trained reactions in our relationship with self, others, and the world. The first step is to acknowledge that there is dukkha in our life; in fact, without seeing dukkha as present there is no motivation to investigate the causes and conditions that create it. The second true reality of all beings is the recognition that there is a causal set of links that have resulted in dukkha. This cycle, interdependent co-arising, stands as the template for personal transformation and provides explanatory power regarding the development of psychological distress. Buddhist explanations of the cause of dukkha differ from other philosophical and religious systems in that they do not posit an external agent who causes dukkha or to whom we can appeal for the end of dukkha (Gethin 1998). Instead, Buddhist cosmology is consistent in that dukkha occurs at both the universal and individual levels and the cycle of interdependent co-arising (paṭiccasamuppāda) that governs the arising, enduring, and dissipating of dukkha is the same in each level. That is, as a general principle, it proposes that all things arise through causal links as consequences of multiple causes and conditions (Harvey 2013b). Specifically, it refers to the cycle from ignorance to birth, ageing, and death.

This is a key concept in the understanding of how distress is created and warrants a detailed discussion. The cycle of interdependent co-arising describes both a macro-level lack of awareness of the cycle itself and a microlevel one of repetitive, unskillful actions and their consequences. These links can be an individual arising of experiences or occur across lifetimes. As a cycle, it actually has no beginning point per se however ignorance of the cycle itself or of our mental state is typically taken as the origin and activation of the cycle (SN 2, 1-2; Harvey 2013c). From this follow mental formations, consciousness, form, the six senses, sense contact, feeling tones, craving, attachment, becoming, birth, and old age and death. Although seemingly linear, each link arises and can be transformed through a multiplicity of causes and consequences in and of itself. When moving in the direction from ignorance to death, it becomes clear in this second reality of life that nothing occurs by itself. The three poisons (root kleshas) of attachment, aversion, and delusion act as propellant of this cycle from ignorance to death. In colloquial terms, our desire for what we do not have, rejection of what we have, and confusion about the interconnectedness of intentions, kleshas, actions, and consequences reflect ignorance of reality and result in a never-ending spiral into dissatisfaction and distress.

McMahan (2008) noted that this traditional view of interdependent co-arising reflects a more dismal perspective of life with little hope to be found in its multiplicity of causes and conditions, a rejection of symptomatic relief from the travails of life, and its almost impossible goal of nibbana/nirvana. He pointed out that contemporary interpretations of interdependent co-arising emphasize the interconnections or web-like nature of the process. That is, where the traditional view counsels disentanglement from the vicissitudes of life, current Buddhist perspectives encourage an engagement with life in all its amazing complexity. These perspectives also emphasize interbeing, a term offered by Hanh (2005, 2007) and one which shifts attention to the relational rather than self-focused attempts at transformation. In fact, by seeing that all beings are connected through thought, word, and action, the practice of transformation of the kleshas becomes even more urgent as an ethical necessity. Furthermore, engagement rather than distancing parallels the intention of mindfulness programs to connect with life in its entirety rather than withdraw from its challenges.

The third true reality is the acceptance that there is a way out, a way to address dukkha, and that the prognosis is good. This path out of the eternal cycle of interdependent co-arising is through the practice of extinguishing the three poisons. Typically referred to as attaining nirvana/nibbana, it is sometimes misunderstood to mean we simply stop feeling for and about everything. In some cases, it is held as a condition we strive for to transcend the trials of the world, be a dispassionate observer of all phenomena. However, because we are never outside the world and continue to be challenged by its vicissitudes as well as the multifactorial outcomes of interdependent co-arising, the transformational process is one that must be sustained continuously. The fourth and most intricate true reality is the treatment for the arising of dukkha and ministration of the treatment protocol. The Eightfold Path comprises practices that cultivate discernment among actions, thoughts, and speech leading to wholesome ways of being as opposed to those resulting in unwholesome ones. The steps in the path are view, intention, speech, action, livelihood, effort, mindfulness, and concentration. They are designed to cultivate mental faculties that transform the three poisons and reverse the cycle of interdependent co-arising. Conventionally, each step in the Eightfold Path is referred to as “right” view, intention, and so on. However, to avoid implying a singular way of having a view, more flexible descriptors are used.

The practice of the Eightfold Path begins with the development of clear thinking or view and cultivation of clear intention; this is the wisdom factor of the path (prajna/pranna). This cluster of the Eightfold Path also forms a feedback loop to the first noble truth by training the mental faculties to see the problem clearly and approach it with appropriate intentions. The second cluster of the Eightfold Path is made up of skillful speech, appropriate or ethical livelihood, and skillful action; this is the path of ethical conduct (sila). It would be fair to say that actual mindfulness practice resides in this cluster as we negotiate through relationships with self, others, and the world. Along with the cultivation of clear view and intention creates the conditions for wise choices in transforming dukkha. The third and final cluster is meditation (samadhi) and is composed of well-directed diligence or effort, well-trained mindfulness, and cultivated concentration. This factor of the Eightfold Path is the technical aspect of practice; it feeds into and underlies the development of the other clusters. It provides a mental state that is calm and focused so that the interconnected relationship can be seen clearly and managed wisely. Implied in the four true realities is the necessity for cultivating a clear, steady mind in order to meet our distress, taking personal responsibility for examining the cause of that distress which may include seeing our role in creating the distress, accepting the help that is available, and finally engaging in the process that alleviates the distress. As an explanatory model of how psychological intervention works, the four true realities articulate the process in psychotherapy and the issues a psychotherapist could encounter.

Despite its apparent simplicity, each of the steps requires in-depth therapeutic work and is a cauldron for resistances and projections. Buddhist psychology expands each of the steps through models of cause and effect all of which are complex and beyond the scope of this chapter. Mindfulness practices are both the process and content of developing an ethical way of being that in turn reduces the occurrence of dukkha. Ultimately, the intention in understanding the complex and interconnected systems of how psychological distress arises, endures, and can dissipate is to cultivate ethical choices that enhance well-being of self and others.

10.2 A Buddhist Perspective of Psychological Components in Mindfulness Programs

Mindfulness programs set the path of cultivating a more intimate relationship with our experience as a proximal goal with the ultimate outcome being a more intimate relationship with others and the world (Wyatt et al. 2014). Based on the tenet that dukkha arises because of reactive tendencies (attachment, aversion, and delusion; Bodhi 2008), mindfulness practices take up the intention of clarifying wisdom, ethics, and stabilizing skills so that whatever is present can be seen, touched, heard, tasted, smelled, and perceived in ways that are unclouded by preconditioned selfconcepts, emotional dysregulation, and overburdened sense systems. That is, we take up the practice of mindfulness so that decisions and choices are wholesome, useful, and beneficial. Mindfulness programs typically focus on opening up tightly held self-perceptions, stabilizing emotional reactivity, and clarifying how triggers set off the physical and psychological systems.

10.2.1 Self-concept

Self is an intricate term that encompasses awareness of who we are through our actions and external events, our interconnectedness through relationships with others, and our sense of agency over our inner and outer environments (Baumeister 2011). Our knowledge of who we are, how we are in external and internal states, is a lens through which we view and evaluate our experience of positive or negative outcomes. Physical and mental illness impact our self-concepts as functional, independent, and perhaps even invulnerable individuals (Thoits 2013). Depending on the degree to which these self-perceptions are affected, it can play a role in our recovery (Markowitz 2001; Tekin 2011). In Western psychology, the concept of self contains a sense of agency and the presence of an agent, a doer of deeds, thinker of thoughts (see Tuske 2013 for discussion of nonself and the issues it raises for Western philosophy). A cultural perspective of independence and individuality directs the factors of this inner self and attaining an independent, separate selfhood has been considered the mark of personal development. In the context of cognitive theories, identity is defined by schema or aggregates of worth, characteristics, relationships with others, and aspirations in the world. A challenge to any one of these schema sends ripples of disruption through the identity, and the closer the schema is to an aspect of self that is valued, the more impact these ripples will have. Traditionally, psychological distress is viewed as our response to these challenges, typically framed as a response to a threat to self-constructs. Well-being is the restoration of the sense of self as whole or repaired.

Buddhist psychology takes what initially seems to be a diametrically opposed view by holding that no absolute, agentic self actually exists (Gethin 1992/2001, 1998). The Buddha’s teachings on “no-self” have been the source of many, many debates over what he meant and how congruent it may be with Western ideas of self (Tuske 2013). Gowans (2003) and Harvey (2013c) describe the Buddha’s teaching of nonself as contextual rather than absolute. In the quotidian, we may speak of an empirical self as a convenience to communication. This empirical self has no reality beyond serving as a device for relating ones mental and physical state. Beyond this, there is no substantive self that exists independent of the five aggregates or channels through which the world is experienced and is permanent. Just as every event or experience arises from an innumerable and unknowable number of causes and conditions, no single event or feature can completely locate or define a fixed self (Harvey 2013a). The intricacies of causes and conditions that mitigate against seeing self as fixed and unitary are perhaps the most important and useful aspect of mindfulness as a means of addressing psychological distress.

Most individuals experiencing psychological distress present for treatment with a sense of self that was viewed as solid and unchanging (Wyatt et al. 2014). Following a negative life event, such as illness, injury, or loss, this self is seen as damaged or changed in ways that are unacceptable. The desire is for treatment to return them to the state before the precipitating event and to fully understand the cause and effect so that it can be prevented from ever happening again. In Buddhist terms, this stance is one of delusion or a resistance to seeing what reality now exists. Grief for what was lost, wanting what cannot be retrieved, or demands for compensation for the loss can be seen as types of attachment to what we believe defines our self. Refusal to acknowledge limitations from injury, a diagnosis of physical or mental illness, or a rejection of treatment for manageable diseases such as diabetes or chronic illnesses reflect aversion or anger. Regardless of which root klesha is activated as a defense against seeing the consequences of our current state, the motivation to respond is based in the delusional belief that what was lost is what defined who the person was.

In Buddhist terms, what is perceived as self is a compilation of five aggregates (skandhas/khandhas) or channels through which the world is experienced: form, feelings/sensations (assessment of experiences as pleasant, unpleasant or neutral), perceptions (recognition of object), mental formations (opinions, preferences, ideas), and consciousness (self-awareness; Bodhi 2008; Gunaratana 2012). For example, an individual may report that they are aware (consciousness) of pain (sensation) in their broken leg (form). They see the situation as unfair (mental formation) because they cannot walk well enough (perception) to work and will become bankrupt (mental formation). Out of this flow of experience, a self that is defined by the circumstances as worthless emerges. Aversion to their circumstances leads to dukkha as they struggle with accepting their situation and may not make discerning choices that lead to well-being (wholesomeness). Alternatively, the situation may be one that seems positive on the surface. An athlete may see their physique (form) as something extremely pleasing (feeling) and admire the strength and muscular features of it (perception). They may assess their state as valued in the eyes of others or gaining admiration (mental formations) and be aware of the way they are admired (consciousness). In this scenario, a self that is valued for its specific form emerges. This attachment to form as a defining aspect of self leads to dukkha when time and events result in the inevitable changes of the body. Attachment, aversion, or misperception of any combination of these five aggregates results in dukkha, whereas viewing them as fundamentally impermanent results in the insight that nothing uniquely defines a self that is enduring and sufficient. This understanding further leads to seeing experience as a ceaseless flow of body, emotions, sensations, and thoughts. Self then becomes an ever-changing property of what causes and conditions are present. It emerges as conditional to the flow of events and is not attached to any singular aspect. Thus, in the Buddhist perspective, self is multidimensional, mutifaceted, and multidetermined. It is flexible, adaptive, and creative; dukkha arises when it is perceived as contingent on a single thing, experience, or capacity to perform.

In a mindfulness treatment program, attachments to the way things were, rejection of how things are now, and confusion about the whys and what ifs are explored through dialogue with the participants. Inquiring with curiosity into perceptions and consciousness as well as explorations of mental formations and perceptions about events and responses to them create the space in which faulty perceptions can be observed and mental formations can be shifted (Kabat-Zinn 2013). Clinging to ideas shifts to releasing the mental rigidity; aversion and anger shift to approach and kindness; delusion and confusion shift to clarification and a willingness to be with not knowing what the outcome will be. As the concept of self evolves from a fixed definition of “this-is-who-I-am” to “just-this,” illness and wellness are contained simultaneously without contradiction.

10.2.2 Emotion Regulation

Mindfulness practices offer the opportunity to be present to arising emotional states and to shift our relationship to them (Segal et al. 2012). Emotions are an essential part of making decisions, organizing actions to achieve goals, and can be adaptive and useful (Fairholme et al. 2010). However, suppression, avoidance, or lack of awareness of emerging (typically unpleasant) emotional states can result in decisions that are not adaptive or beneficial. Ekman and Davidson (1994) conceptualize emotions as arising from a confluence of cognitive, behavioral, and physiological responses to an external event or an internal. Most models of emotions and their expression involve awareness of sensations, ability to attend or be present to the experience, an appraisal system to determine the meaningfulness of the experience, all of which finally generate a response based on prior learning, exposure, and situational factors. Lazarus and Folkman (1984) placed emotions (affect) as part of a multimodal determination of experience involving behavior, affect (emotion), sensations, imagery, and cognition. Buddhist psychological understanding of emotions is similar in viewing emotions as what may be evoked by feeling tones but arise from mental formations (Analayo 2003; Gunaratana 2012).

All experiences evoke emotional responses. Someone who loses his job, a woman whose partner or child dies, a couple whose marriage breaks up, or a student who fails an important final exam experience emotions to varying degrees of intensity and which may be considered understandable given such loss. The specificity of the emotions is linked to the individuals’ interpretation of the meaning of that event to them. The person who lost the job may respond with understandable anger if he felt unfairly treated; the woman responds with sorrow and grief as her loved ones die; the couple feels confusion if they feel wronged or misunderstood; and the student reacts with helplessness if he believes he put in the best effort he could. These are typical responses and considered normal in the face of the circumstances.

Dukkha arises when emotions are dysregulated; that is, they are over- or undercontrolled in response to loss, pain, and other human conditions. A corollary of the root kleshas, attachment, aversion, and delusion/ignorance is that they both are and lead to emotionally driven, reactive actions and that reactivity reflects a level of emotional dysregulation. When an individual is caught in what is called an afflictive mental factor, their mind is clouded and it results in a misperception of what is actually transpiring internally and externally. From a general psychological perspective, when caught in the turmoil of attachment, the focus is primarily on reducing the threat of losing the object of our attachment and not on the reality of what that object of attachment is. For example, the person who lost his job may feel his self-worth as a provider threatened and not see that the job was not beneficial to his well-being. Initially, emotional distress is normal in a case of losing a job; however, his attachment to self-perception as being a provider can lead to intensifying the emotional experience (fear, anger, frustration) and can lead to behaviors that may not be helpful such as quickly taking another job that is just as harmful to his health. Similarly, suppressing grief after the loss of a loved one in order to seem strong or intensifying anger through blame in case of a relationship breaking down are examples of emotional dysregulation or afflictive mental factors.

In Buddhist terms, these reactions reflect continuing to cling to aspects of self. The root kleshas fuel these negative emotions which in and of themselves are not inappropriate but that the rationale for viewing them as threats to our identity is based in a misperception. The normal grief for the loss of a partner or child is suppressed because its expression is believed to reflect badly on the individual. Confusion becomes an obstacle to finding a new job because the individual believes he is being negatively judged. Anger interferes with letting go of the relationship because of a belief that others are to blame. Problem solving for the student is limited because of a loss of confidence, which is part of his sense of self.

Although it appears to be predominantly a cognitive process, the initial reactivity is sparked from an inner experience of discomfort. Internal experiences such as sensations of tension, numbness, flutteriness can evoke reactive behaviors if prior learning has associated clusters of sensations with a specific negative emotion. Essentially an avoidance of the internal experience, it signals low distress tolerance or difficulty staying with an uncomfortable inner experience (see Boulanger et al. 2010 for detailed discussion of experiential avoidance). While it may be that negative emotions have their source in clusters of arising internal sensation, traditional therapies have focused on the external expressions of aggregated sensations such as depression, anxiety, and anger. As Aronson notes, however, in Buddhist approaches, emotions are not typically addressed, and the focus is more on using our experience to realize impermanence, transform the kleshas, and reverse the cycle of interdependent co-arising (Aronson 2004).

Nevertheless, the ability to stay with the internal sensations of emotions does become the purview of a Buddhist model of distress in that meditations train equanimity for inner experiences by simply noting feelings such as pleasant, unpleasant, and neutral in tone are present. As well, the concept of no-self mitigates against personalizing unpleasant experiences thereby creating a space between the experience and allowing for a skillful response to the experience. An additional benefit to the practice of noting sensations is the likelihood they can dissipate before dysregulation is activated. This cultivation of presence to unpleasant experience becomes very relevant in addressing the physiological aspects of stress in reducing reactivity to the experience itself.

10.2.3 Stress Models

Buddhist and Western conceptualizations of stress and distress vary and differences may be more related to their level of inquiry than an actual disjunction in concept. In Buddhist terms, all phenomena result in dukkha or distress; in fact, life as it is, or samsara, is dukkha. The central model of the causation of dukkha is worth repeating here because psychological distress infuses the cycle and begins with a misguided thinking process (Gunaratana 2012). The cycle of interconnected 12 links are the initial lack of awareness of the way dukkha arises, mental formations, consciousness, form, the arising sense phenomena, contact, clinging, attachment, self-making, and inevitably the rounds of (re)birth, old age, and death. In Buddhism, escaping or being liberated from this cycle constitutes the reduction or better, the cessation of stress/distress. While it is possible to be liberated from the process of clinging and attachment and become someone able to live well, the commitment is to be fully liberated from the entire cycle. Western perspectives of stress/distress might be seen as addressing a section of the cycle of the generation of dukkha, that is, treating the connections from ignorance and mental formations to attachment while leaving issues of (re)birth, old age, and death to spiritual and medical practitioners.

Endocrinologist Seyle (1974) was among the first to investigate and define stress (he later noted it was better referred to as “strain”) as the physiological response regardless of the positive or negative nature of the stimulus and that pathological outcomes occur when the stress is unremitting. Later models include McEwen’s (2002) model of allostatic load, which more closely aligns with the idea that strain on an existing biological system results in its eventual breakdown. Porges’ (2011) polyvagal theory posits a complex model of neural regulation of the autonomic system. Relevant to the earlier discussion of sensations and their evolution into dukkha is the proposal in the polyvagal theory of neuroception as the mechanism through which defensive stances are triggered. According to Porges (2007), external events and intentionality in social contexts are appraised via neuroception and discerned for their threat value, which activates the appropriate response, defense, or engagement.

The human system has evolved to be adaptive to both low- and high-threat environments, and the neural system is staged to appraise the degree of safety in a hierarchical manner with the higher cognitive functions able to override lower “primitive” systems in responses to threat. Tempering the upregulation of the nervous system when under stress or threat and activating the downregulation to reestablish homeostasis relies on a well-functioning feedback system. Typically, under prolonged stress, the lower appraisal system is reinforced to be highly active and the feedback provides what can be seen as misperceived levels of threat.

Although still being tested as a viable theory that supports a neurobiological role in emotional responses and a source for social engagement behaviors, Porges’ theory offers several conceptual hooks to understand the cycle of stress and distress. Most important to this exploration of Buddhist principles that underlie clinical mindfulness is that an accurate appraisal of threat may not necessarily lead to a discernment of wholesome action. For example, neuroceptive appraisal of low threat can still result in activation of sensations that aggregate to anxiety-based responses, or high threat appraisals may not inhibit engagement in the situation (Porges 2007). In other words, visceral awareness is insufficient to make wise or wholesome choices if clear comprehension of the situation is absent.

Equally relevant to developing a Buddhist perspective on clinical mindfulness, polyvagal theory proposes that calming of the activated system and soothing behaviors can be elicited via the autonomic nervous system. This proposal suggests breath-related meditations play a role in calming and soothing, a state that is important at a physiological level so that cognitive processes have access to clear incoming information. A psychophysiological perspective also opens the door to viewing clinical issues as multifaceted and the need for integrating biological, physiological, and psychological factors as important contributors. Furthermore, it removes the implication that symptomatic relief through mindfulness practice is a shallow and ignoble goal; from the perspective of the polyvagal theory, addressing symptoms (or more precisely the sensations that arise as symptoms) plays an important role in reducing reactivity.

10.3 Foundational Dharma Teachings in Mindfulness Programs

The attainment of liberation depends on the realization of the causes and conditions that give rise to dukkha. That is, the crucial step towards liberation is to cultivate discernment of what is a fabrication of desire (clinging and attachment, aversion and anger). To set out on this path, we first begin to train the mind to calm and then to see clearly so that wisdom in the form of discernment can develop. The cultivation of tranquil calm states is called samatha practice and the cultivation of wisdom is called vipassana practice. Together these form the foundational practices. However, it is important to be aware that there is an ongoing discussion whether samatha (single-pointed meditation developed in the first stages of the Anapanasati Sutta) and vipassana (cultivation of insight as in the later stages of the Anapanasati and the Satipatthana Suttas) together are required to attain nivarna or if vipassana is sufficient. Mills (2004) argued that the interaction of samathaplus-vipassana are required otherwise true discernment and moral concern for others is not likely to arise. Turning to the Pali Cannon, we read of the Buddha using the simile of a crossroads at which sits the lord of the city (consciousness) who is approached by “a swift pair of messengers” ( samatha and vipassana) conveying a message “in accordance to reality” (teachings on nibbana; SN 35.245; Bodhi 2000). While recognizing that such debates are important, for the purposes of this discussion, we will rely on the Buddha’s teachings that both arrive at the same time to perform their duties.

The two primary suttas referenced in mindfulness programs are the Anapanasati and Satipatthana Suttas, awareness of breathing and four ways to establish mindfulness, respectively. Analayo (2013) raised some questions about the Anapanasati Sutta’s guidance with respect to their logic and intention; however, these intriguing inquiries are beyond the scope of this discussion (see Chap. 4). The Anapanasati and Satipatthana Suttas are typically read as working hand in hand to cultivate meditation through the awareness of the breath and mindfulness of body, feeling, mind, and phenomena as its full practice (see Chap. 5). Rarely mentioned or written about together as a practice framework, Hanh’s (2006, 2009a) commentaries on the two sutras are likely the most accessible in both exploring and integrating them as a protocol of practice. Mindfulness programs tend to focus on the principles of the Satipatthana primarily, and vipassana is the primary meditative approach (Cullen 2011). However, the content of the Satipatthana is not immediately obvious in most clinical programs. That is not to say a mindfulness program’s curriculum should walk in lockstep with the suttas; the experiential and clinical aspects of such programs necessarily take precedence. Yet, it is important to hold these teachings in the forefront in order to understand how mindfulness is to be facilitated and to address issues that may arise in its subtly complex practice.

10.3.1 Anapanasati Sutta

The Buddha taught the Anapanasati Sutta, also called the sutta on mindfulness of breathing, as the base practice which brings the Satipatthana to fruition (Buddhadasa 1976; Hanh 2009a). Elegantly set up, the 16 stages beginning from awareness of the breath itself and ending with liberation from attachments and craving are organized as 4 tetrads of meditations that tuck into the 4 ways to establish mindfulness (Satipattthana). There are several excellent commentaries available on the nuances and details of this important sutta (Buddhadasa 1976; Hanh 2009a). The following section is a synopsis of the tetrads and integrates the teachings into components of a mindfulness program. The framework of the Anapanasati Sutta is deceptively simple; however, to assume the practice is equally simple would be a mistake. Despite appearing linear and steplike, the process is actually iterative with later stages doubling back on the first ones. The first and second tetrads, each consisting of four stages of meditation, develop awareness of the in- and out-breath, the length of breath, awareness of the body, and the perceptions and mental formations that arise from the body. Buddhadasa (1976) explained that this tetrad is the most crucial to the practice and should be explored in detail. Stages I and II of the first tetrad are considered the preparative stages for practice and the implication is that we are practicing ethics by virtue of restraint; the attention being on the breath prevents unwholesome actions, thoughts, and speech when in a meditative state. They invite the practitioner to be aware of the breath as it enters and exits the nostrils and then to be aware of the shortness and length of the breath.

The effect of the length of the breath on the state of mind and body is also observed. Buddhadasa (1976) noted that a normal state of mind is associated with easeful, long breaths, and the practice is on noting how the breath will change and be an indicator of our circumstances. This observation becomes useful in teaching mindfulness as it links the physiological, physical, and emotional states of the practitioner. In this stage of practice, the mind is trained to be “tethered” to the breath and weaned away from its typical distractions. The practice is primarily one of concentration training; nevertheless, it cultivates associated qualities of zeal, gladness in its realization, single-pointed mind, equanimity, full awareness of the experience, and the physical body. In stages III and IV, awareness of the body is developed through the observation of the impact of breathing on the body and the arising insights to impermanence, dukkha, and no-self. The breath is seen as conditioning the physical body as the body sustains its mental states. This sense of fully knowing the in- and out-breath in the body is the first way to establish mindfulness of the body in the body (see section on Satipatthana below). Beginning with stage III and continuing to stage VIII, the cultivation of ethics, concentration, and wisdom comes to the fore.

In mindfulness programs, meditation instructions tend to be brief with the intention of allowing the participant to explore the process freely. However, it would be useful to address some aspects of stage I and II overtly to avoid misunderstanding or misdirection. When attending to the breath, for example, practitioners notice that the act of bringing attention to the breath results in a tension or a change in the length and depth of the breathing. The Anapanasati Sutta invites experimentation with placing attention on the breath and the expansion/contraction of chest and abdomen during the in- and out-breath cycles and observing the outcome. The mind in its untethered state is easily distracted and this often leads to frustration for beginning meditators. The metaphors of training a puppy to sit and stay, or guiding a friend back to the path, are helpful. It is also helpful to indicate that returning to the breath is an active choice to turn away from mental activity that is unhelpful. At this level of practice, the breath is also being connected to the body, as a conditioner of the body.

The second tetrad, stages V to VIII, follows the same formula and uses feeling tones (pleasant, unpleasant, neutral) as the object of meditation. It is a practice that leads knowing the nature and characteristics of experience. As awareness of feeling is trained, perception of that feeling being “my feeling” becomes connected to it and that is followed by thoughts of whether it is negative or positive. It is in these connections that the cycle of interdependent co-arising is relevant because the value given to the feeling gives way to craving and attachment. The connection of breath to feeling allows the observation of the cognitive process of perceiving what is felt and how preferences (wanting what is pleasant, aversion to unpleasant) arise and cease. From a clinical perceptive, stages V–VII offer entry for practice to issues of distress avoidance and emotion dysregulation. These stages offer a mental processing model for the way in which the preferential mind arises and offers insight to the approach/avoidance tendencies. Revisiting the cycle, sense impressions (the contact of an object with the six senses) lead to feeling which in turn results in perception of the object typically as personal (“my”). This then results in a (cognitive) valuation of the experience as good or bad. In pain-related experiences, the sense impressions can project rapidly to a personalization of pain and an appraisal of pain being bad or unwanted. Aversion evokes various avoidance behaviors that may be temporarily helpful. However, these actions condition the body to react with tension and thereby sustain the cycle of distress avoidance.

Stage VIII is a practice of using the breath to disengage from a runaway thinking process or any experience of overwhelming perception or feeling. In effect, the practitioner cycles back to stage I and reconfirms the technique of breathing until the coarse breath becomes fine and subtle. The difference from the practice in stage I is that the object of meditation is the perception and feeling, not the breath. The feeling and perception are said to become calmed as well, by which is meant that their distractive capacity is reduced and they have less power to hijack thinking. This tetrad is folded into the second way to establish mindfulness of feelings in the feelings.

The third and fourth tetrads focus on the states of mind. The third tetrad, stages IX–XII, is practice in opening to the mind as being impermanent, dukkha, and having no-self. To accomplish this, the previous strategies are used for noting and conditioning the mind. As confidence in the process grows and results are experiences in terms of both concentration and calming the mind, a satisfaction of the mind arises. Insight arises as well in relation to the nature of our experience, its history, chronicity, and trajectory. It is important not to lose sight that this practice is consistently unfolding in the context of the Eightfold Path and that the cultivation of ethics, concentration, and wisdom are the base of practice. Ultimately, the full awareness of the mind results in liberating it from its own sense impressions and from ignorance that opens the cycle of interdependent co-arising. This stage of practice is also considered the culmination of the moral training, a transformation of the attitudes and behaviors that form an obstacle to mindfulness. This tetrad is connected to the third way to establish mindfulness of the mind in the mind.

The fourth tetrad, stages XIII–XVI, focuses on the development of the practitioner’s mental state so that the nature of all phenomena can be understood. This tetrad is associated with the fourth way to establish mindfulness of phenomena. Here, the awareness is on the flow of experience and its aim is the cultivation of wisdom or insight to experience as impermanent, constantly fading, ceases, and can be let go. Through contemplation of the five aggregates, six internal sense bases, and interdependent co-arising, insight to the constantly changing nature of our experience is attained, not as an intellectual exercise but as an inner experience.

Hanh (2009a) described this stage as seeing the wave and the water. Although waves form and have many different sizes and shapes, they rise and fall, appear and disappear. Yet they do not lose their essence as water. He also points out that this final stage is a bittersweet one. We may feel pessimistic by its message of impermanence that to most of us means loss. We can also see the potential of joy in realizing that everything is interconnected and that we are not limited by and can be liberated from our concepts of status, possessions, or relationships. This insight facilitates letting go of anxiety, fear, anger, and all the things that form the basis of craving and attachment.

In the context of a mindfulness program with all its demands for alleviation of dukkha, it is important to note that there can be pressure to leap forward into content of the third and fourth tetrads by pointing to the “good news” of liberation from dukkha or to use that possibility as an enticement to practice. However, this distracts from and becomes an obstacle to practice. The iterations through breath, body, feeling, and mind are crucial building blocks from which insight to phenomena arises. These last two tetrads, being concerned with cultivating wholesome states of mind, require a process of observing the impact of negative states of mind. There can be a reluctance to turn towards such inner experience; however, it is important to convey that knowing these negative states are present is an important practice ( dhukkha, the first true reality of all beings). Accepting the reality of depression, anxiety, grief, and so on are the first step to knowing what needs to be healed.

This is a complex sutta and, like most Buddhist teachings, is intricately intertwined with other teachings. To convey all of its complexity in a mindfulness program would be burdensome; however, familiarity—experiential and intellectual— with its intentions as it cultivates each stage of meditative capacity is important. Questions and experiences arise about the usefulness of meditation throughout a mindfulness program and, because there is a strong emphasis on sitting meditation, a facilitator needs to be reasonably versed in the intent and purpose of the Anapanasati Sutta.

10.3.2 Satipatthana Sutta

The Satipatthana Sutta is likely the central teaching on the cultivation of mindfulness in the Theravada tradition. Step by step, it cultivates awareness of the body, feeling, mind, and all phenomena of mind; each of these can be thought of as platforms on which mindfulness rests or ways in which to establish mindfulness (Goldstein 2013). However, the cultural use of this sutta is not without controversy. Sharf (2013) pointed out that this dominance of the Satipatthana is a recent phenomenon and related to attempts by Burmese meditation teachers to make Buddhism more accessible to lay persons. This attempt shifted the emphasis from samatha and developing higher levels of consciousness (jhānas) to “bare awareness” of the flow of our experience and the idea of living in the moment. Sharf and McMahan (2008) noted that these concepts form the foundations of Buddhist modernism and now is transcultural. Nevertheless, as the primary framework of current uses of mindfulness practice, it is important to examine the structure of the sutta and, perhaps more important, its approach in cultivating mindfulness.

Gunaratana (2012), Hanh (2006), Goldstein (2013), Silananda (2002), and Analayo (2003, 2013) have written several excellent commentaries; the books by the first three authors are accessible for the general practitioner, while the latter two authors present a scholarly approach. Hanh (2006) and Analayo (2003) have examined the terms ekayana and Satipatthana. Ekayana or ekayano maggo is determined as “one path” or the “direct path leading to one goal.” Sati is translated as mindfulness or awareness with upatthana meaning attending. Mindfulness then is rendered as “attending to the current situation” (Analayo 2003, p. 29). Sharf (2013), drawing from a number of sources including Gethin (1992/2001), indicated that sati imparts a sense of “remembering,” not as memory, but as a recall of an interconnectedness of all things skillful and unskillful. In that context, sati conveys a discernment of wholesome from unwholesome actions that are accessed in the vast web of recalled experiences. Important to practice yet rarely mentioned in mindfulness programs, the refrain of the Satipatthana fosters a positive environment for practice. It is a repeated reminder of the essentials of the practice: contemplate inner, outer, and both inner and outer experiences; contemplate the nature of impermanence; recognize what is unfolding in this moment without mental discourse; and let go of clinging to any one event that arises in our mental or physical realm of experience (Goldstein 2013). Drawing primarily from Analayo’s (2003) translation and commentaries, we now examine the four ways to establish mindfulness and their relevance to contemporary interventions.

The first way to establish mindfulness is to cultivate mindfulness of the body. In the Anapanasati Sutta, this is the first tetrad, which focuses on breath and how it conditions the body. The practice as described in the Satipatthana cultivates mindfulness through awareness of breathing, body postures (sitting, lying down, walking), its activities, and details of its composition. One intention of this practice is to bring awareness of the physical aspects of our body, suspending preference and judgment. The purpose is not to separate body from mind but rather to see the body as an intricate set of related parts that function best when closely attended. A second intention of this practice, which can include some contemplations we might find unpleasant, is to bring into awareness all aspects of the body—pleasant, unpleasant, and neutral to our conception. It aims at reducing the desire for the pleasant parts and aversion to unpleasant parts of our physical nature. This in turn reduces the discursive thoughts, deepens concentration, and allows insight to arise. In clinical mindfulness, bringing attention to the body is a trigger for aversion. Typically, participants in a mindfulness program are attending because they have met with significant physical challenges through physical or chronic illness or injury. They may also be disconnected with their body because of emotional experiences connected to the body. These can range from experiences of anger and anxiety to experiences of sexual or physical abuse resulting in post-trauma symptoms. The protective and defensive stance to their situation is to use distraction, denial, or an alternate hyperintense experience. Bringing attention to the source of their suffering with all its psychological issues (feeling betrayed by the body) may not feel like a possible or useful approach. The concept of equalizing pleasant and unpleasant aspects of the body is a beneficial practice for a less combative presence to it. Practice with the breath also offers insight to the ever-changing flow of physically based experiences and the observation of how the breath conditions the body is likely to be very useful. As noted in the Anapanasati Sutta, the breath becomes more fine and subtle, the body calms, and discursion diminishes along with its attendant distraction. We feel less yoked to our body and at its mercy; our concepts of the body as ill or globally malfunctioning are moderated by a view that is more balanced with aspects that are functioning well.

The second way to establish mindfulness is to cultivate mindfulness of feeling. In Buddhist terms, feeling (vedana) implies knowing or experiencing and includes bodily and mental feelings. It can be confusing initially because in Western terms “feeling” refers to emotions; here, it means pleasant, unpleasant, or neutral tones of an experience. Emotions are considered a state of mind and relegated to the next section of the Satipattahana. The practice is one of noting that initial moment of assessment: Is this pleasant? Is this unpleasant? Is this neutral? The intent is to capture that momentary experience before the appraisal system activates and our preferential mind creates a reaction. Analayo (2013) suggested this level of attention might allow access to our intuitive sense, that moment of “I knew (I felt there was something wrong)” which we tend to dismiss after the cognitive process takes over. Another intention is to discern whether the feeling is activating old habits that tend towards unhealthy choices. Again, this reflects the link of the cycle of interdependent co-arising where craving and attachment are activated based on pleasant or unpleasant feelings. Working with unpleasant and pleasant feeling in a clinical context connects back to the tendency for emotional dysregulation discussed above. Avoidance of what is unpleasant and craving what was pleasant result in irritation, frustration, and generally negative emotions. Neutral feeling is of particular interest in clinical populations for two reasons. First, in groups who are disconnected or dissociated from their inner unpleasant experiences, most feelings may be relegated inaccurately to feeling nothing or numb. Not being aware of what is arising often leads to an experience only being felt when it is intense and therefore not immediately manageable, for example, anxiety and physical pain. This in turn triggers a cycle of overcontrolling the unpleasant experience, which only surfaces again unpredictably. Second, neutrality may not be seen as part of the overall experience. Most individuals who experience pain or anxiety report that their experience “comes out of the blue” or “comes and goes without reason.” That is, the experience arises as an unpleasant one and then disappears (perhaps after hours of suffering) only to start again. They may note that the period in-between pain surges are spent in worry and tension, anticipating the next round. When they can note the full round of an experience in which unpleasant feeling arises, endures, dissipates, and then is followed by a brief moment of transition, a neutral space, impermanence is apparent. In this neutral zone, the breath is able to have a foothold and the opportunity for better choices arises.

The third way to establish mindfulness is by contemplation of the mind. There are intense debates about the definition of mind, its location, and its function. Mind here is defined as consciousness whose function is awareness (Gunaratana 2012) and it is present in every aspect of experience just as heat is present in every part of a chili pepper. It arises from contact between an object and the senses giving rise to a sense-consciousness. In other words, it arises from innumerable causes and conditions, is impermanent, and is only known by its impact on the body and feelings. In this stage of the Satipatthana, awareness of the quality of what arises as mental events is cultivated through the qualities of ardency, clear comprehension, mindfulness itself, and concentration. Also called forth in the previous two ways of establishing mindfulness, these mental qualities are likely most necessary in contemplating the mind with its tendencies to be colored by the five aggregates (of which it is a part as well) and veer towards attachment, aversion, and delusion/ignorance. The third stage of the Satipatthana is perhaps the most obvious in its applicability and usefulness in a mindfulness program. Buddhist and Western psychology have a common ground in acknowledging the powerful role of mental events in physical and mental health. There is an important distinction however in where they enter to the aspect of mind. Cognitive-based therapies examine and work with the content of mind, that is, thoughts and thinking patterns. In the Satipatthana, the specific contents are viewed as impermanent and the focus of intervention is the quality of the contents or event in the mind. If the content leads to poor choices, negative outcomes, or further deepening the cycle of dependent co-arising, then the response is not to challenge the irrational nature of the mental event or its sequelae. It is to cultivate antidotes for the attachment, aversion, and delusion/ignorance they activate. The intervention is transdiagnostic and not limited by details of any individual’s personal history or event. This is useful as a guide consistent with the principles of mindfulness programs, which cultivate the experience of the event and not the story woven about it.

The fourth way to establish mindfulness is to contemplate the ways in which experience arises. The five hindrances, five aggregates, six sense spheres are the focus of practice, and the intention is to clarify and transform the impediments to awakening. Buddhist psychology places primary value in the way our perception forms the entirety of our experiences including the experience of self. This cycle is conditioned by our desires and preferences and is, for the most part, distorted and preserving of a self. The intention of practice is to unwind from the initiating stimuli that lead to the cycle of conditioning and see reality.

In a mindfulness program, the five hindrances (desire, anger, sloth and torpor, restlessness and worry, and doubt) provide grist for the mill. The hindrances arise after the first week of home practice and endure in various ways providing a wealth of opportunities to encourage observation of how they trigger frustration, anxiety, and avoidance. The five aggregates also provide opportunity to examine our perceptions of who we are, who we think we are, and how that results in the choices we make for ourselves. This is the central context of a mindfulness program and fostering the qualities of ardency, clear comprehension, mindfulness, and concentration can be supportive and encouraging for participants. The practice of Satipatthana establishes an ardent, concentrated mindfulness that cultivates clearly understanding our experiences and their outcomes. The Eightfold Path of wisdom, ethics/virtue, and concentration is embedded in each stage, and it is the focal point of the practice. The core of this teaching is that we are refining a way of remembering all in our past that brought about dukkha and its cessation, temporary as this latter may have been. The Satipatthana framework is quite explicit in noting that the intention and focus is the cultivation of discernment and the transformation of the three poisons. In other words, we are cultivating our ability to speak, think, and act in ways that do not perpetuate the creation of dukkha for others and ourselves. This development of a moral stance to our relationships is the practice of sila or virtue ethics (Harvey 2000; Keown 2005). In the contemporary use of mindfulness, there are many discussions specifically related to the cultivation of ethics (McCown 2013; Monteiro et al. 2014, 2010) and its seeming absence. Hanh’s version of ethics practice, the Five Mindfulness Trainings (Hanh 2007) and the Fourteen Mindfulness Trainings (Hanh 2005) for his formal students, are ways in which ethics can be practiced. Monteiro et al. (2010) and Cayoun (2011) describe other ways of integrating ethics into a mindfulness program.

10.4 Subtle Dharma Teachings in Mindfulness Programs

10.4.1 Teachings from Theravada

Two significant suttas play a role in mindfulness programs but are typically not prominently mentioned. The first addresses the misunderstanding about emotional states and how they are activated. In the discussion above on emotional dysregulation, it was noted to be an important rationale for cultivating mindfulness practices. The dyad of the Theranamo and Bhaddekaratta Suttas offer a framework by which to understand the intention of practice and how feelings are actually transformed in the context of human relationships. The second teaching is from the Metta Sutta, a popular practice however not always addressed in mindfulness programs as a cultivation of a moral conduct. Its role as one of the four brahma-viharas is also important in developing a balanced practice of mindfulness.

A Solitary Life The Theranamo Sutta (SN 21.10; Bodhi 1995) tells of the Buddha’s instructions to an elder monk in the sangha who had a preference for living in isolation. When the sangha expressed concerns about the monk Theranamo, the Buddha spoke with him to inquire about his chosen way of life. Hanh’s (2011) commentary draws together the Theranamo (SN 21.10), Bhaddekaratta (MN 131-14), and Migajala (SN 35.63) Suttas to expand the Buddha’s teachings that living a solitary life, cut off from others does not result in peace or freedom from distress. The Buddha pointed out that even in such solitary conditions, we are in the company of our craving, attachment, and other mental states (SN 35.63; Bodhi 1995). We are still bound by our mental formations, delusions, and the six senses. Rather than rejecting the world, which we inaccurately assume causes our distress, a better way to live alone is to free ourselves from craving and attachment. In that way, we truly are living away from the source of our dukkha.

In the context of emotional regulation, these suttas address our tendency to control our external environment in order to feel emotional stability. It is not uncommon for participants to lay the source of their distress in the external aspects of their lives. It is the spouse, children, boss, traffic, illness, or life itself (viewed as something separate from themselves) that is the cause of anxiety, depression, anger, and helplessness. It is also common to hear that they would like to eradicate emotions, not feel so much, or be indifferent to the arrows that trigger pain and suffering. They would like to “get rid” of “their” anger, depression, panic attacks because these are the actual causes of their distress. Past and future are also seen as sources of distress. Memories of painful events and worry about what might be painful events to come are powerful triggers of suffering in the present. As their experiential tolerance increases through the course, this better way to live alone becomes more apparent. The cause of dukkha is no longer external to such an absolute extent. It is now experienced as internally generated or interactive. As the true source of suffering is understood and the capacity to be attentive to it in the present increases, past and future take their place as mental events. The liberation for participants in a mindfulness program is not only from the distress of feeling vulnerable to a world full of triggers but also from actual social isolation or desperate need to connect without discernment of the quality of relationships.

Metta and Its Companions The Metta Sutta or loving-kindness meditation is likely one of the most beloved practice in Buddhism. It is said that the Buddha taught metta to monks who were living in the forest and were afraid of tree deities who were trying to scare them out of the forest (Sn 1.8). The practice of metta was intended implicitly to cultivate moral conduct in the face of challenges. In other discourses, the Buddha’s teachings address the impact of anger (AN 7:60), resentment and negative speech (MN 21 & 128) and the cultivation of good-will as their cessation (see Buddhaghosa 2010 for consolidation of discourses). Gunaratana (2001) described metta as loving-friendliness, a quality of mind that can only be cultivated when we relinquish our rigid views and confused thinking. Chodron (2001) connected aggression and suffering to ignorance, the first link in the cycle of interdependent co-arising. She noted that in order to transform dukkha, we need to recognize our interconnectedness to realize that what we wish for ourselves, others would also wish for themselves. The practice of metta is sometimes a difficult one for mindfulness program participants to embrace. The sequential offering of metta to loved ones, neutral persons, those who have hurt us, and then to all beings can elicit resistance and feelings of frustration or confusion. Sometimes, the practice of offering metta to someone who has caused hurt is not included if there is reason to believe it would be a trigger for emotional reactivity. However it may be offered in the session, metta practice is fertile ground for teaching moments and discussions of self-care and other care. Participants discover that it is easier to offer to other than to themselves or that having offered it to themselves they touch the level of depletion they feel.

Metta is also one of the four brahma-viharas or “limitless qualities” of mind (Chodron 2001); the other three are compassion, equanimity, and resonant joy. It is important to practice all four brahma-viharas (SN 46.54; Bodhi 2000) as an interconnected set of moral stances. Compassion (karuna) is defined as the ability to be with one’s own or another’s suffering. It plays a significant role in cultivating a sense of connectedness; it is differentiated from empathy, which carries an implication of resonating with the other’s suffering. Compassion has been related to the capacity to activate a sense of feeling safe (safeness) and the ability to tolerate distress (Gilbert 2005, 2009). A growing practice is one of self-compassion, which is the cultivation of our stance to ourselves as we suffer. It is also a mindfulness training program in and of itself (Germer 2009; Gilbert 2009; Neff 2011). Equanimity (upekkha) is the capacity to see beyond the layers of perception and mental formation into the essential interconnectedness of all things. Young (2011) described equanimity as a stage of mind that does not impede the experience of pleasant or unpleasant feelings. Thus, the feelings retain their untainted ability to motivate, inform, and direct skillful actions. In mindfulness programs, this capacity is necessary to reduce reactivity not only to emotional distress but also to physical pain.

Unselfish joy (mudita) is the ability to feel joy in another’s joy. In the cultivation of unselfish joy, Buddhaghosa (2010) recommended not beginning with a loved one because mudita is not intended to arise out of the experience of mutual care. He recommended beginning with a good friend, progressing to a neutral person and then a hostile one. This progressive mode of practice eventually cultivates impartiality towards categories of beings that have formed as a result of our mental formations and perceptions. Monteiro and Musten (2013) proposed that in order to appreciate others’ joy regardless of the quality of relationship we have with them, we must first have cultivated the capacity to clearly know our own joy. In that sense, the term “resonant” joy coveys the idea that we understand the other person would feel joy and our understanding is independent of our feelings towards them.

10.4.2 Teachings from Mahayana

Kabat-Zinn (2011) described MBSR as rooted in the Theravada and Zen traditions (Soto and Rinzai). According to Kabat-Zinn, the teacher–student relational process of koan work was the inspiration for the teacher–participant dialogue of inquiry that occurs in mindfulness programs. Part Socratic, part verbal akido, the inquiry aims to clear away the detritus of the delusional thinking process to expose the clear knowing of our experience as it is happening. It strives to undermine an external authority, an expert who has the answers. Although there are no details of which teachings from Zen play a specific role in mindfulness programs, it is not difficult to see that some concepts addressed above in the Theravada teachings also have a Mahayana/Zen parallel. Rahula (1978), despite a somewhat argumentative stance towards Mahayana teachings, connects Zen with the Anapanasati and Satipatthana Suttas and many other teachings on attaining arahhantship or enlightenment.

Within Zen teachings proper, there are frameworks that help to clarify the process of mindfulness practice. Kapleau (1980) described Yasutani’s three essentials of Zen practice as cultivating great faith, great doubt, and great effort. As our practice unfolds, we learn to doubt the face value of our experience. We begin to suspect that there is an intrinsic wellness/goodness in which we can have faith. Because of that faith, we expend great effort to know truly the reality of our experience. These three Zen essentials unfold in the process of mindfulness programs. The Prajnaparamita, Lotus, and Diamond sutras, among many others, offer deep insight into interbeing, loving-kindness, and the ephemeral nature of experience (Conze 1958; Hanh 2009b, 2010; Pine 2001; Tamura 2014). Mahayana sutras however pose a challenge in application to mindfulness approaches simply because of their complex and often tightly woven metaphoric nature. As challenging as it can be for mindfulness program teachers to both grasp and apply the Theravada Suttas, the challenge of doing so with the Mahayana/Zen texts can be just as daunting. Nevertheless, a solid acquaintance with the essence of the primary Mahayana/ Zen sutras is important to providing an overarching perspective of the essence of a mindfulness program. 10.4.3 Zen Koan Principles and Practice

Kabat-Zinn’s (2011) connection of koan practice and the teacher–participant relationship in mindfulness interventions creates a space for participants to explore their experience without fear of judgment or censure. Understanding Zen koan principles helps to encourage this exploration in two ways. First, koan study is an intricate process of relationship - building between teacher and student (Loori 2006b) and the face-to-face inquiries lead to letting go of our typical intellectual and philosophical approaches (Yamada 2005). As in the teacher–student relationship in koan practice, the mindfulness teacher conveys that every aspect of an experience is legitimate material for inquiry. Unlike the sometimes confrontational or unruly forms in Zen koan practice, but in keeping with professional conduct guidelines, the teacher’s role of pulling the rug out from under the student takes on a softer aspect of turning the participant towards their intellectual assumptions or experiential state. Second, Zen koans are useful as a device to foster the “don’t know” mind (Sahn 1997). As teaching stories or frameworks for inquiring into the nature of our experience, koans are a rich source of encouragements to move beyond the mental constructions and directly connect with the experience in the moment. Below are two koans that offer insight to typical struggles among participants of a mindfulness program and an overarching model that informs the intention of taking such a program.

Sen-jo’s Reality Koans are conventionally pithy sketches of dialogue or a scenario through which teachings are transmitted. Koans can also come as stories; Caplow and Moon (2013) have compiled twenty-five centuries of narratives by and about women teachers that shine the light on many aspects of our life. The story of Senjo and her soul is one; a Chinese folk tale (Aitken 1991; Shibayama 2000; Yamada 2005) about a young woman who decides to leave her parents and an arranged marriage in order to be with the man she loves. Stricken with homesickness and guilt after many years away, she and her husband return only to find her parents confused when she claims to be their daughter. As far as they know, Sen-jo has been in their home all these years, lying in her bed unable to engage with her filial duties or her life. The question is asked: Which is the real Sen-jo?

The question posed by Zen teachers is not about the literal or metaphoric reuniting of Sen-jo with her soul but an inquiry into the idea of dualistic identity (Arnold 2004). Inherent in the question is the implication that the split is real and that resolving the conundrum requires determining which part is truly real and which is fantasy or dream. This overlooks the story material that wraps around the koan and it fails to appreciate that the paradox in the story is imposed by our own separation from ourselves (Hori 2006; R. Sasaki quoted in Loori 2006a).

Sen-jo presents us with a direct experience of the delusions that arise when we are asleep to who we are and the joy when we are awake. The components of her story also touch on duty, commitment, an honest desire for a loving relationship, and a wish to be a valued part of community. These themes wrap around the koan and inform us of the structure that supports our life. However, the deeper structures of the story are the assumptions and beliefs we hold about who we are and how easily we can be taken apart.

Dukkha arises when we experience ourselves as separated from who we believe we are and from others around us. We attempt to resolve this suffering by various means; in both Buddhist and clinical terms, we engage in denial, obsessions, and mental and physical addictions. We fail to see that the dualism between one self and the other is an illusion, albeit a sometimes helpful illusion. The real question therefore is not which is real Sen-jo but rather how can Sen-jo’s experiences and actions become a pilgrimage of identity (Whyte 2001) so she can exist fully and in alignment with each of her roles. It is typical in clinical mindfulness programs to hear participants speak of their loss of identity. Their experiences with depression and anxiety construct selves of hopelessness and helplessness; injuries that result in loss of mobility and functionality generate beliefs of worthlessness. As painful as the life event can be, dukkha is created when the reality of its occurrence and what that means are resisted by clinging to the past, aversion to the present, and confusion about the future. It manifests as the desire to find and reunite with the healthy self. This belief that a split has occurred creates a misperception of life as dualistic: good/bad, pain/no pain, and healthy/ill. It is to this dharma door that the clinician as mindfulness teacher can invite participants to engage in an exploration of impermanence and identity as fluid and ever changing. Similar to the story of Sen-jo, the stories that wrap around the suffering are peeled away; identities as whole, complete, and all the absolute terms are themselves deconstructed. The states of sleep and wakefulness to experience as it unfolds are examined.

Ox Herding The second koan that is useful to understand the overarching theme of mindfulness is the story of the ox and its herder. The “taming of the bull” describes our spiritual journey through art and poetry in which the bull or ox is our mind and the herder is the practitioner who seeks to tame that mind. In some renditions, the ox is our Buddha nature not yet realized and in this guise as an unruly ox slowly changes color from black to fully white signifying its transformation. The journey is illustrated in a series of pictures beginning with a sighting of the ox and culminating with returning to one’s life having mastered the mind (Loori 2002; Pine 2011). Some sets have 8 or 12 pictures; however, the most common set, attributed to Chinese Zen master Kuo-an Shih-yuan, contains 10 representations of the stages of the path to enlightenment (Kapleau 1980). As Loori (2002) points out the ox-herding pictures form a map of the possible direction that practice can take while still holding a sense of not knowing how that path will unfold. The journey of the ox and its herder also parallels that of the participants in mindfulness programs.

In the first picture, searching for the ox, we become aware that there is a questioning, a wish to know ourselves better or even some aspiration of feeling better than we typically do. Participants in a mindfulness program come with a wide range of suppositions and desires. Pain and suffering has led them to doubt their capacity to manage their life and the ability of any intervention to heal them. The second picture, traces of the ox, depicts our sense that there is something we can do; we may discover meditation, yoga, or some form of practice that provides structure to our life. As we work in this stage, we are also confronted with the reality that there is no quick fix to our dukkha. Participants often return after the first week feeling frustrated, dismayed, or even angry that mindfulness practices such as the body scan are not helping. Some do comment that the practices were amazing in transporting them to a blissful state; these are typically “flights into health” and the wise clinician–teacher learns to value the experience, but not become caught in the delusion of cure. The third picture, seeing the ox, gives us a glimpse of the ox and, although it is stuck deep in the bushes, we have a sense that something solid is present. Participants begin to have glimpses of something unfolding in their practice; there is a sliver of faith building as they get samples of being in their body or noting feelings arise and dissipate. The fourth picture, catching the ox, is a powerful moment of encountering the mind in all its raw unruliness. Most participants report feeling a surge of old thought patterns and doubts as they continue to practice. The dualism they have constructed about mindfulness good/pain bad begins to break down and wisdom arises albeit tentative and inconstant. There is a point in the program where participants either “buy into” the larger possibility of living well or settle for the symptomatic relief they have acquired over the first half of the program.

The fifth picture is the taming of the ox through unrelenting diligence. Old habits are always ready to reassert themselves and, at the same time, we are cultivating trust in our motives and our skills. Compassion arises and with it self-compassion as we learn to befriend ourselves. At this stage of practice, participants begin to feel the confrontational relationship they have with their body and emotions remits, even if only for a while. There are more encouraging encounters with self, other, and the world. Riding the ox home, in the sixth picture, imparts a sense of ease and cooperative connection. The struggle with self and its vicissitudes softens and participants begin to understand how they can be triggered and how to unhook from those types of connections. The seventh picture shows the ox is gone and the person remains. It points to the teachings of nonself as we realize that there is not absolute mind (ox) that controls or directs us. Instead, who we are emerges out of a myriad of causes and conditions. Participants express a sense of letting go of the ideas and objects that they believed defined them. There is less fear of being controlled by their unruly ox or insight that the ox was really never the problem in the first place. In the eighth picture, all constructs of “self” and “ox” are gone. The seeker and what is sought have transcended their labels. This state comes after lengthy and dedicated practice and may not be evidenced in such a short period of mindfulness training.

The last two pictures represent returning to the source and entering the marketplace. Kuo-an added these two pictures because the truly realized Zen person does not stop at the dropping away of concepts (Kapleau 1980). He saw the highest spiritual development is in our skillful functioning in the quotidian. With deeper and more ardent practice, we are intimate with our experience, embodied, informed by wisdom, live by sila, and steadied by practice. We enter into our life with compassion for others and actions that are embedded in that care. This entry into the marketplace is the maturing of our practice. We see our practice as the means to transform dukkha but are no longer attached to it in an obsessive way. It becomes simply what we do, moment-by-moment, be it brushing our teeth, fixing a meal, caring for others, or meeting our dying moments. It may be unrealistic to expect participants of an 8-week program to enter these stages given many mature practitioners spend their lives in this process. However, the time limitations of typical mindfulness programs speak strongly to the need for ongoing practice opportunities.

10.5 When Dharma Meets Distress

The teachings in the broader context of dukkha, suffering, and the wish to be liberated from it is universal. The path however differs for each individual. Ultimately, it does involve commitment to a process and a willingness to learn how to be different in the face of the realities of life. Dogen, Zen master and founder of the Soto Zen tradition, expressed the essence of how and why we practice as Buddhists: “To study the Buddha Way is to study the self. To study the self is to forget the self. To forget the self is to be actualized by myriad things. When actualized by myriad things, your body and mind as well as the bodies and minds of others drop away. No trace of enlightenment remains, and this no-trace continues endlessly” (Tanahashi 1985). And yet, our intention and trajectory of practice is not that different from the person registering for a mindfulness program. There is a desire to be free of psychological struggles, mental distress, and perhaps even physical pain. In the Buddhist context, however, there is an understanding at the outset that this is a lifetime process demanding tremendous patience and its end point is not relief but liberation. It is understandable that practices which seem to veer away from this lifetime commitment can be seen as “quick fix” ways to lessen suffering without a full transformation.

However, dukkha now presents at a scale and intensity that calls for a different approach to transformation and healing. Mental illness and mental distress that arises from physical illness is now a global concern. The statistics are consistent across countries and show a dramatic rise in depression, anxiety, and other psychological disorders (CDC 2011; Marcus et al. 2012). Not only is there an enormous emotional and financial burden on the lives of individuals who suffer from these mental illnesses but also an impact at an economic level (Kazdin and Blase 2011). The consequences of losing employment because of mental illness and the ensuing stigma also have significant impacts on individuals, their families, and society as a whole (Pescosolido 2013). Turning away from this scope of dukkha is inconceivable especially in the face of evidence that suffering benefits from treatments that can be consistent with the fundamental principles of Buddhism.

In order for Buddhist teachings to have the fullest of impact in secular/clinical settings, the principles of what is being transformed and why it needs to be must occupy the foreground of any mindfulness program. While the context of its clinical application is to effect change in presenting symptoms first, the broader and deeper effect of practice on the person must be held close. The balance for the clinician– teacher is to guide the practices so that relief is attained but the larger issue of transforming greed, anger, and delusion are not lost. At the same time, in typical Zen fashion, it is necessary to relinquish investment or hold on the outcome to be a Buddhist-based one.

10.5.1 Upaya in the Treatment Approach and Protocols

The potential for mindfulness-based programs to be beneficial for all those who suffer is significant. However, we must be aware that the people who attend Buddhist venues will not be the same as those who seek psychological assistance and sometimes the two become conflated. In the 35 years since the inception of MBSR, the connection of MBIs to Buddhist thought has become common knowledge. This may be a double-edged sword, attracting those who hope that a spiritual path will take them out of their psychological distress and those who may be willing to explore a path that offers a perspective significantly different from the familiar. At the same time, some participants will be wary of anything that sounds or feels like Buddhist teachings including terminology, ringing of bells, meditation, and yoga movements. Perhaps Buddhist practitioners who attend a program for their own psychological needs will feel a greater discomfort in the secularization of the principles and practices. Each person will require upaya or a skillful approach to convey the practices, challenge misunderstanding, and feel reassured that they are being met at their level of understanding and commitment.

Upaya is also necessary in determining the content and form of practices in a mindfulness program. While Buddhist and Western psychology may take differing perspectives of mental disorders and their function (Sharf 2013), the application of mindfulness must be seen as a Buddhist-based intervention in a cultural context (societal, medical, etc.) that has its own criteria for safe and effective protocols. Thus, issues such as diagnostic criteria, medication use, vulnerability to psychosis, and so on need to be considered when selecting practices and forms of interaction. Regardless of the source of the intervention or the details of its protocols, most individuals coming to a treatment program simply want to get better. Buddhist principles of transforming suffering and Western applications of those principles tend, for the most part, to honor that aspiration. However, there are considerable challenges to accomplishing this process that can arise at many levels. Thus, for the potential secular/clinical teacher, it is important not to confuse a commonality of intention (alleviation of suffering) with a commonality of therapeutic models. Mindfulness in a Buddhist context is not the same as a therapeutic approach with added protocols of meditation or awareness of experience. This means, the onus is on the aspiring teacher to be well informed and educated in the similarities and differences in Buddhist mindfulness practices and their underlying principles as well as the therapeutic model of their own training.

Abbreviations

AN Anguttara Nikaya; access to insight, http://www.accesstoinsight.org/index. html

MN Majjhima Nikaya; Bodhi (1995)

SN Samyutta Nikaya; Bodhi (2000)

Sn Sutta Nipata; access to insight, http://www.accesstoinsight.org/index.html

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Lynette M. Monteiro is a registered psychologist and the director of training at the Ottawa Mindfulness Clinic. She completed an MA on neurobehavioral correlates of human communication disorders and a PhD investigating the efficacy of methylphenidate in the treatment of attention-deficit hyperactivity disorder (ADHD) in preschool-aged children. She is trained in cognitive behavioral therapy (CBT), cognitive processing therapy for veterans and active military personnel, mindfulness-based treatments (mindfulness-based stress reduction (MBSR), mindfulness-based cognitive therapy (MBCT), mindfulness-integrated CBT (MiCBT), mindful self-compassion (MSC)) and Buddhist chaplaincy. Dr. Monteiro’s primary treatment interest is with military and first response members experiencing post-traumatic stress disorder (PTSD), and she serves as a personnel selection psychologist for police and military units. As a clinical professor at the University of Ottawa, she is in charge of training PhD clinical psychology candidates in an ethics-based mindfulness intervention. She is coauthor of Mindfulness Starts Here.