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Buddhist Publication Society
Kandy • Sri Lanka
Copyright © Kandy; Buddhist Publication Society, (1982)
First Edition: 1982
BPS Online Edition © (2009)
Digital Transcription Source: Buddhist Publication Society and Access to Insight Transcription Project.
For free distribution. This work may be republished, reformatted, reprinted and redistributed in any medium. However, any such republication and redistribution is to be made available to the public on a free and unrestricted basis and translations and other derivative works are to be clearly marked as such and the Buddhist Publication Society is to be acknowledged as the original publisher.
Troubled Relationships: Transpersonal and Psychoanalytic Approaches
Fetter 1: Sense Desire (Lusting After Sense Pleasure)
Fetter 2: Anger
Fetter 3: Sloth and Torpor
Fetter 4: Restlessness
Fetter 5: Doubt
Mindfulness Meditation as Psychotherapy
Techniques of Bare Attention
Using Mindfulness Training With Neurotic Patients
The Watcher Self
Suiting Technique To Client
Implications For The Therapist
The use of a transpersonal approach in working with couples in a troubled relationship, in addition to facilitating gratifying change within the relationship, may also promote individual changes of a transpersonal nature. Joseph Goldstein (1979), a Vipassanā Buddhist meditation teacher, recently suggested that, whereas in the East a monastic approach is common, in the West the Dharma (i.e., that which is ultimate) may more likely manifest in the working out of the vicissitudes of relationships. The same skills and insights that allow us to soothe the “ruffled feathers” and hurt feelings of a troubled relationship may be the ones that allow us to let go of fetters to spiritual growth.
Psychotherapy of troubled relationships usually involves clarification of communications and learning of constructive communication. In addition, in insight therapy, the fears, angers, and tensions that arise are used to focus on the transference distortions, thus making conscious those forces, usually of an infantile nature, that have been unconscious. Once they become conscious, these forces can usually be dealt with by the more rational and adult aspects of the personality.
An extra, constructive dimension may be added to traditional psychotherapy by incorporating a transpersonal approach. This could involve sharing with one’s clients some of the therapist’s personal philosophic beliefs via the use of “teaching stories.” It might include the suggestion that clients consider beginning a meditative practice if this is not already part of their experience.
This approach is most readily adopted when a couple is already committed to spiritual goals. In such cases it may be helpful to articulate the idea that, whereas man’s basic goal may be the enlightenment state, working on one’s relationship may facilitate the elimination of those fetters which prevent us from experiencing this state. Specifically placing the therapeutic work in such a broader context may encourage clients to put maximum effort into the work.
Sharing a transpersonal approach with one’s clients may also make the work on relationships a bit less grim. The sense that on some level all of our experience may be a dream or an illusion allows some distance from the situation and enhances the ability to view things from a more balanced perspective. This in no way negates the value of the work which may be seen as an effort to keep the dream from becoming a nightmare. In addition, and perhaps most importantly, developing a stable, loving, caring relationship may ultimately allow the partners to direct their energies towards their spiritual work from a secure rather than an exhausted depressed position. Even with clients who are not particularly aware of or interested in the transpersonal dimension of work on themselves, many of the insights derived from spiritual practice may be incorporated in the work without specifically labelling them as such. For instance, the concept of “attachments” and the pain that often accrues as a result of attachments to people, to things, etc., is understandable in any context. Likewise, the concept of “impermanence,” which can be pointed out by focusing attention on any aspect of a person’s experience, can diminish the anxiety that people experience about their current unhappy state, thinking that it will last forever.
Before drawing the specific parallels that I see as existing between working on an individual spiritual practice and working on a relationship, I want to delineate a bit more how I think both the traditional and the transpersonal approach may each be particularly appropriate for specific aspects of relationship problems. In actual practice a skilled therapist should be able to move back and forth between both modes.
A major area of relationship difficulty arises as a result of unconscious conflicts that get played out in the arena of transferences and counter transferences in the relationship.
According to Freudian theory, these usually represent unresolved issues stemming from early developmental periods. In couples operating with a relatively high degree of ego functioning, these unconscious conflicts may be dealt with through the use of traditional psychotherapeutic techniques. The insights from uncovering these unconscious motivations may be incorporated into the adult aspects of the couple’s personality, thus attenuating the friction between them.
Another major area that often comes into focus in relationship therapy is one in which the conscious and unconscious styles of the partners, stemming probably from identification with early parental figures, are irritating the other partner. A very neat and orderly person whose central values are thrift and hard work may feel threatened and anxious in a relationship with a person with a more relaxed, less intense personality. While the individual styles may not either be pathological, they may nevertheless be abrasive to one another. In such instances a transpersonal approach may be helpful. As each partner becomes more aware of how attached he or she is to the idea that his/her style is “right,” it may make it easier to countenance the idea that both are just styles, and neither is “right.” The story of the Sufi Master, who is arbitrating a couple’s disagreement, is helpful here.
A couple came to the Sufi Master with a disagreement. After listening to the husband’s story he says, “You are right.” Then following the wife relating her side of the story, he says to her also, “You are right.” His aide, a bit bewildered, takes the Sufi Master aside and asks, “How can they both be right?” The Sufi Master turns to him and says, “And you are right, too.”
The style of needing to be “right” sometimes reflects character armour, covering fears of a primitive, existential nature. Focusing on these fears which become exposed as the style is threatened may allow the individuals to give up their adversarial stance and consider their own personal motivations. This is not to suggest that putting people in touch with their own existential anxiety makes them feel any better. My sense is, however, that it shifts the emphasis from placing the difficulty in the other person, or in the relationship, to the recognition that one needs ultimately to do one’s own inner work.
It goes without saying that neither the approach of insight therapy or transpersonal therapy is appropriate in those situations where self-destructive or abusive behaviour is manifest in the relationship. Such behaviour usually reflects infantile and/or narcissistic personalities stemming from early life trauma, and attention needs to be given to the ego defects involved. A transpersonal approach may be misinterpreted: “It’s her karma, I don’t need to be responsible.” Nor is insight therapy appropriate: “Do Not Add Insight To Injury.” Socialisation therapy, Reality therapy, and basic nurturing in whatever ways it can be constructively assimilated would be appropriate.
It is of course crucial in the early stages of therapy that the level of mutual caring be evaluated. If there is not a reasonable amount of caring, in addition to the negativity, then the work to help the couple will probably fail.
In tracing the parallels between spiritual work and relationship work I will use as a reference the five categories of hindrances, derived from the Buddhist tradition (Goldstein, 1976), which are considered to be fetters keeping us from the balanced mind necessary to achieve the enlightened or unity consciousness. Among the many ways to organise the problems of relationships, I chose the “five fetters” approach because of the striking parallels between the hindrances arising in meditation and the impediments to a gratifying relationship. This approach also leads to the conclusion that we may be able to loosen many of our spiritual fetters through working on relationships. A role of the therapist is therefore to point out how every point of friction or discontent in a relationship actually is highlighting a hindrance, or fetter. Each partner therefore becomes, rather than an adversary, a trusted, even if challenging, companion. This approach also mitigates in favour of continuing in a relationship, whenever possible, instead of ending it and moving on to another one. In the same way, staying with one meditative practice through its difficult, tedious stages is generally felt to be more fruitful than changing. Where both partners became allies in a mutual agreement to be present as living teachers for each other, consistently and over a long period of time, it becomes more and more difficult to keep up individual systems of self-deception. It is important to stress that “teachings” are not always experienced as loving, but with skilful practice may become more that way.
Although, in actual work with couples, multiple fetters often are present and overlap each other, for purposes of discussion, I will outline them separately. Each of the following categories attempts to correlate a specific hindrance in meditation practice with a specific problem in relationships and also to suggest appropriate psychoanalytic and transpersonal approaches.
The fetter of desire as it arises in meditation practice is generally a thought about an attachment to some pleasure available somewhere that would make the meditator more comfortable than his/her current situation. Or, it might manifest in a sense of greed, a desire to have more of a pleasurable experience, either current or remembered. The antithesis of these feelings would be contentment with one’s current state, whatever it is. In a relationship, this pattern emerges as the notion, on the part of either or both of the partners that they would be more gratified, and thus more content, with another partner. One or the other partner might become involved with fantasied or actual relationships with other partners, thus removing energy from the ongoing relationship. Or one partner, unable to recognise his/her own unconscious desires, might project these desires onto the partner and then feel hurt or angry over imagined infidelities.
From a psychodynamic point of view, such problems might be approached with insight therapy. The expectation that somewhere there is a partner who would be totally gratifying is often a recreation of an Oedipal expectation. The uncovering of this Oedipal wish often allows individuals to have a more realistic expectation of their real life partner.
In a transpersonal context, my working assumption would be that each individual is entirely responsible for how he or she experiences their situation. To cite a culturally unfamiliar example, Seikan Hasagawa, in Essays on Marriage (1977), indicates that prior to enlightenment we cannot know who would be the “best” partner. He feels that spending time and energy picking a partner is not as important as living the married life skillfully. His view is that it does not matter whom you pick as a partner since you can use the struggles of the relationship for spiritual growth: Although this approach may be inappropriate for our lifestyle and culture, it does seem to have certain advantages insofar as if one’s spouse is chosen by others, one may not necessarily or readily perpetuate one’s own neurotic propensities in the selection.
The issue of greed usually manifests in relationships in struggles over money, power, and the need to have more things go one’s own way rather than accommodating the partner. Traditionally this might be approached by examining the roots, in his or her background of the need to have more, perhaps stemming from some deprivation in an early developmental stage. In a transpersonal context, the emphasis might be on the impossibility of ever satisfying greed, since all things and experiences are by nature impermanent. In addition, perhaps the therapy can uncover and work with some of the existential anxieties (e.g., I won’t have enough, I’ll die or starve, or I need to be richer, more powerful, etc.) that underlie the need to have more. A helpful illustration is found in the teaching story of how a monkey can be caught:
A coconut shell is hollowed out, fastened to a tree, and a banana placed inside. The opening is large enough for the monkey to put his opened hand in. On seeing the fruit, desire arises and that monkey reaches inside the coconut shell, grabs the fruit but is unable to remove his clenched hand which is holding the fruit. He sees the hunters coming to kill him, but he wants the fruit, stays trapped and dies. To be free he had only to “let go.” We all have so many “bananas” that we clutch at, stay trapped and therefore do not live as fully as we might.
When anger arises as a hindrance in meditation it is often difficult to let go of, because it carries such a strong energy charge, thus seducing the mind to stay preoccupied with it. A similar situation prevails in a relationship situation where, once angry feelings have been introduced into the situation, it is difficult for either partner to back off into a position of tolerance and to let go of protecting their own point of view. Thus whatever behaviour was originally anger-producing becomes entrenched as the partners become adversaries, each trying to prove that they are “right.”
Traditional psychotherapy might be used to expose and explore the fears that lie behind the angers. These fears often reflect unresolved, and/or traumatic infantile or early childhood events. For example an individual angry with a partner over the partner’s relaxed attitude towards money may come to see that the anger is masking an underlying fear of lack of enough money, goods or security to survive. Presumably the now more adult ego can practically care for these earlier needs and fears.
In a transpersonal context, the use of “teaching stories” is often a gentle and effective tool. There are stories from the Sufi and the Buddhist traditions, and probably from other traditions as well, that highlight the idea that we really cannot be sure, from our limited world view, of what is “right” and what is “wrong” or what is fortunate, or unfortunate, and that remaining doggedly attached to one point of view prevents our experiencing a wider awareness. One illustration follows:
The Chinese farmer had a horse and was therefore able to plough many fields and was thus fortunate. One day his horse ran away and he was thus said to be unfortunate since he could not plough his fields. The next day his horse returned, bringing with it a wild horse. Now he was thought to be doubly fortunate: So the next day the farmer’s son went to tame the wild horse, was thrown, and broke his leg. Now the farmer is said to be unfortunate again. The next day the King’s army came to the farm looking for soldiers to go to war, but were unable to take the son because of his broken leg. So now the farmer was said to be fortunate. And so the story goes on.
In a situation where it is appropriate, a mettā or loving kindness meditation might be suggested. In this meditation one forgives others for their hurtfulness and asks forgiveness for oneself. Along with this, positive wishes for the happiness of others as well as for oneself are made. When introduced into a meditative practice this meditation appears to undercut the fetter of negativity and anger. Partners in an embittered relationship who endeavour to practise this meditation may find that it dissolves feelings of enmity.
In classical meditation practice this fetter manifests as lack of energy, and failure to bring enough vigour into the practice to produce any substantial results. A commensurate amount of energy to that needed to realise any spiritual goals is needed to achieve a level of real communion and mutual satisfaction in a relationship. In the West, the media message via TV and movies often gives the impression that quick, often impossibly romantic solutions to relationship problems are possible. This may predispose us as a culture to disillusionment and disappointment when we are confronted with the inevitable shortcomings of a real life relationship. In addition, the emphasis in the more “new age” elements of the culture seems to be more oil “moving on” when a relationship becomes uncomfortable, rather than on working it out.
During the honeymoon phase of a spiritual practice or of a new relationship, there is often a sense of unlimited expectation. Suzuki Roshi (1970) calls this “Beginner’s Mind,” and cites this as just the element that may be the vital contribution to real spiritual gains. I’ve counselled Zazen practitioners to try to cultivate this “Beginner’s Mind” openness and lack of limiting opinion as a part of their ongoing practice.
Partners in a relationship may work in a similar way to cultivate an ongoing freshness or vitality in their relationship. In situations where a lack of energy input has led to a dullness in the relationship, or inability due to past conditioning to respond to changes in one’s partner and a sense of taking each other for granted, the recognition of this fetter can lead to efforts to eliminate it. Specifically, such efforts might include planning on the part of both partners to continually re-clarify communications, to do things that are gratifying for each other, and to remain pleasing and attractive to the other person. Simply developing the awareness that relationships (like meditation practices) do not remain exciting and dynamic on their own but require constant input of renewed energy, may reassure partners that their relationship has not soured because they are unsuitable to each other, but perhaps only because it has been left uncultivated.
One can look at a relationship as a garden that needs constant fertilising, watering and weeding. If this is not done, there are no flowers or fruits. Even the weeds are reburied in the ground so that their energy can nourish the flowers. Weeding, or working on one’s fetters, provides energy which can ultimately be used to nourish the positive aspects of the relationship. Perhaps a prickly cactus garden does not need much tending or weeding, but fruit and flower gardens do.
In meditation practice this hindrance often manifests as difficulty in staying present, mentally and/or physically, in the meditation situation, and in a sense of terrible boredom with one’s current experience. In a relationship this hindrance appears as the “Seven Year Itch.” This syndrome, generally associated with couples who have been in a relationship for a number of years, is not associated with a relationship that is painful or unhappy, but rather with a relationship that is reasonably gratifying but nevertheless humdrum. It is not so much that “Familiarity breeds contempt” as “Familiarity breeds boredom.” The classical reaction to the syndrome is the search for new partners to relieve the restlessness and satisfy the boredom:
Traditional therapy might focus on unreasonable expectations of enduring gratification in a relationship or on other unconscious motivations such as the need to prove, via a new partner, that one continues to be attractive and alluring. A more transpersonal approach might cultivate the awareness that boredom is not a reflection of an uninteresting situation but rather of an unmindful observer. Fritz Perls (1973) is often quoted as saying that boredom always reflects not paying enough attention. To an observer cultivating mindful awareness, everyday situations can be fascinating. Annie Dillard, the naturalist author of Pilgrim at Tinker Creek (1972), describes her awareness of the teeming life that is present in the very small area of seemingly lifeless earth on which she is sitting. Partners in a relationship may perhaps cultivate that awareness which makes even the mundane events of family life interesting. Specifically in terms of the sexual boredom that is implicit in the “Seven Year Itch,” it is possible, for couples who are motivated to do so, to recognise that every sexual encounter is a new experience—similar to, undoubtedly, but in some way different from the previous five hundred sexual experiences. A few clinical examples illustrate the above points:
Mr. A, a corporate executive, and Mrs. A. a housewife, a couple in their 40’s who have been married for 18 years, came for help because of continuing power struggles centering around decisions regarding money, running the household and sexual contacts.
Despite their great angers, both still cared for the other. In addition, both had been involved previously in spiritual and meditation practices. Part of, our work consisted of tracing out the source and effects of a rather hypercritical and punitive early upbringing. These manifested themselves in the (unconscious) transferences to each other and towards me. They were able to see how they were more eager to be right and the winner, rather than be happy—much as a 2–year-old may stay constipated, have a bellyache, but feel pleased that mother could not force him to have a BM.
Mr. B, a 40–year old policeman, and Mrs. B, a 35–year-old childcare worker, came for help as a last ditch measure prior to divorce. Mrs. B felt very dominated and misunderstood by her husband, collected and saved all of her grievances to than be played out by pouting, always being late and other passive aggressive manoeuvres. Some of our work consisted of helping her see how she “selected” unconsciously a husband to duplicate her relationship with her mother whom she also feared and acted out towards passive aggressively. Neither were spiritually oriented in the least, and Mr. B didn’t particularly feel any need to change. He just wanted his wife to be more cooperative and pleasant.
By exposing the unconscious compulsion to repeat her relationship with her mother, Mrs. B was able to see her desire for the infantile gratifications which it was now too late to get, and especially her attachment to her anger which she enjoyed greatly and kept alive by collecting grievances, all the while being frightened. In addition, the teaching story of the two monks and the beautiful girl was very helpful to Mrs. B in seeing how she collected grievances, continually mulled them over and enjoyed being upset by them.
There were two monks waiting on a street corner where there was a good deal of flooding. A beautiful girl was standing there trying to get across but was unable to. One of the monks seeing the situation quickly picked up the girl, carried her across the water and placed her down on a dry spot. The other monk was the meanwhile thinking—how could he do that—we’ve taken priestly vows not to look at beautiful women let alone hold them close to our bodies”—and on and on. A few miles down the road the second monk could no longer contain himself and began to berate the first monk who had assisted the girl. After the berating had stopped the first monk turned to the second and said, “I put the girl down 3 miles back—how come you are still carrying her?” This story is helpful to couples who are grievance collectors.
Thus working on the first 2 fetters, desire and anger, greatly alleviated the marital tensions, and she was now able to express her adult needs directly, to which the husband more often than not responded—ultimately resulting in greater affection between them.
To further help her when she felt flooded, I taught her mindfulness meditation, without calling it that, so that when she experienced anger or fear she learned how to watch the experience without getting caught up as readily as before by providing time to avoid reacting automatically as she used to do.
The fifth fetter is that of doubt, the recurrent concern that one’s chosen meditative path is not a viable one, that the philosophy behind it is false, that one’s teachers are inadequate and/or that one will never be able to make any progress anyway. Parallel doubts arise in a relationship. Questions of whether or not one has chosen an appropriate partner, or whether or not it is too late to change to a new partner, arise not only at times of conflict in the situation, but also, as they do in the meditative situation, at times of comparative calm. Traditional therapy might attempt to explore hidden stresses, such as significant birthdays, work promotions or retirements which testify to advancing age, as being reasons to suddenly evaluate whether it is not too late to change to a new partner in order to get more out of this life. A transpersonal approach might suggest that doubt is just one of the many mind states that arise and pass away naturally, on their own timetable, often unrelated to outward circumstances. In meditation practice it is generally accepted that one of the enduring effects of one’s first, albeit brief, experience of enlightenment consciousness is that the fetter of doubt disappears forever.
In my own experience I have come to believe that the recurrence of doubt about one’s relationship disappears finally at that point in a relationship where enough years of mutual care and mutual struggle, mutual interests and mutual gratifications finally come together in such a way as to suddenly, as in a flash of insight, make it clear to both partners that this is not only the “right” relationship for them to be in, but that the relationship will endure. As in meditation practice, where there is no way of predicting how long it will take for such doubt-dispelling occurrences to happen, there is no way to predict how long it takes for such awareness to occur in a relationship. Perhaps the first ten years of a relationship is the trial cruise and after that the ship might be expected to maintain fairly smooth sailing conditions The challenge is to stay with the difficulties regardless of the number of years, whenever possible, because what is at stake is one of the most fundamental and potentially gratifying situations—an intimate relationship.
Dillard, A. Pilgrim at Tinker Creek. New York: Bantam, 1975.
Goldstein, J. The Experience of Insight. Santa Cruz, Ca.: Unity Press, 1976.
Goldstein, Joseph. Personal Communication, 1979.
Hasagawa, S. Essays on Marriage. Arlington, Va.: Great Ocean Publ., 1977.
Perls, F. The Gestalt Approach. New York: Science and Behavior Books, 1973.
Suzuki, Shunryu. Zen Mind, Beginner’s Mind. New York: Walker/Weatherhill, 1970.
Mindfulness meditation, like any other approach, is most powerful when employed as part of an overall programme of psychotherapy designed specifically for the individual client. It can be a primary, secondary, or supplementary part of any therapy programme, depending upon what is appropriate for the client.
This approach to psychotherapy derives directly from Buddhist teachings. It is therefore relevant to mention the philosophical foundation of the techniques. Buddhist thought and practice have always been directed toward providing the individual with a way to gain insight into life experiences, to perceive more clearly the nature of internal and external realities and the relationships between the two. People continuously and rapidly cycle through a multiplicity of moods and emotional states. This cycling process, saṃsāra, is inescapable as long as its motive powers persist, namely greed, hatred, and delusion. But this process can be seen, transformed, and finally stopped, thus providing people with freedom unavailable to others who are unknowingly entrapped in states of psychological distress.
Buddhism uses both philosophy and direct “therapeutic” intervention to accomplish its goal of enlightenment. Therefore the Buddhist approach establishes logical tenets and then provides a way of personally verifying them. For example, the beginning teachings in Buddhism—the Four Noble Truths—observe that everything is impermanent, including one’s own life, and that the impermanence of the material world is a primary and direct cause of unhappiness (things and people deteriorate and pass away). Any rational mind can accept the existence of suffering and unhappiness, can perceive the impermanence of the world, and can to some degree accept the relationship between them. There are ways out of this dilemma, however. Buddhism offers a pathway of coming to know the mental processes and of working directly with these processes to gain insight into—and to some degree freedom from—entrapment in the saṃsāric cycling process.
The mindfulness meditation described here, when practised diligently and progressively, can potentially lead the practitioner to experience directly the ultimate realities described in Buddhist scriptures. Soma (1949), Mahāsi (1975), and Nyanaponika (1972, 1973) describe the Theravada Buddhist mindfulness as satipaṭṭhāna—sati (“awareness”) + paṭṭhāna (“keeping present”). These forms of meditation are the basis of the mindfulness meditation that is discussed here. It is designed to enhance mental health. First it allows one to see one’s own mental processes; second, it allows one to exert increasing degrees of control over mental processes; and finally, it allows one to gain freedom from unknown and uncontrolled mental processes. This seemingly impossible task is accomplished through what Nyanaponika calls “bare attention” (1972): the accurate, continuous registering at the conscious level of all events occurring in the six sensory modes—seeing, hearing, touching, tasting, smelling, and thinking—without qualitative judgments, evaluation, mental comment, or behavioural act.
How is such an investigation of the mental processes carried out? First, a set of meditative exercises teaches and refines the techniques of bare attention. If one sits quietly with the body comfortable and relaxed, one can practise bare attention through consciously observing the breathing process as one breathes in, pauses, breathes out, pauses longer, and then breathes in again. This concentration on a physical process quickly produces interesting results. Soon, mental events begin to occur and interrupt breath observation. Events external to the body impinge on consciousness—a dog barks, a door closes, the day grows hot, a fly lands on one’s face. Awareness of the breathing process is interrupted momentarily as awareness shifts to the sound or other sensation. Awareness arises that breath observation has been interrupted by something particular; breath observation is resumed. Perhaps a memory rises to consciousness, again disrupting the observation process and shifting awareness to the memory for a time; then realising that a memory interruption has occurred, one resumes breath observation. Awareness of the breathing process may soon be lost again as a fantasy arises and is played out—what to do during vacation, how to ask the boss for a raise; again awareness eventually arises that breath observation has been interrupted, and it is resumed.
After only a few minutes of breath observation, one realises that a continuous chain of mental events is taking place, that awareness is flipping from what one is intentionally attending to, the act of breathing; to innumerable other things—bodily sensations, external factors, memories, fantasies. This constant losing and regaining of conscious awareness of what one is doing takes place thousands of times a day. The initial observation of breathing, or any other ongoing process on which attention can be focused, clearly demonstrates the frequency with which this shifting takes place.
Through such observation and through neutral, nonjudgmental naming of each interrupting factor (remembering, worrying, hearing, imagining), one begins to see and appreciate that mental events jump from one event to the next with a staccato rapidity that is seemingly random and chaotic, even frightening. Naming the interrupting factors begins to provide insight into one’s unique mental processes and identifies the area with which one must work. One person is interrupted again and again by memories from the past; another is plagued by fantasies of performing heroic acts; a third is interrupted by bodily discomfort, sleepiness, or boredom. Becoming aware of one’s primary interrupting factors can be diagnostically and therapeutically significant because one can sometimes clearly see unhealthy, habitual mental processes.
While mindfulness training is not indicated for psychotic, senile, or brain-damaged clients, it can be useful with the large group of so-called neurotic, anxious, or depressed clients. Buddhist psychology, in fact, views almost everyone as neurotic to some degree. The person seeking psychotherapeutic help is only slightly more neurotic than the one who does not seek help. Neurosis may be characterised by ongoing internal dialogues: “I want to find a new job”; “No, you had better not—you might fail”; “You are probably right, but I hate this one so much”. These I’s who populate our minds reflect our neuroses, sources of discomfort, hang-ups, and disunity.
Mindfulness training, then, can be used to see and name mental processes in action. What use is this? If we believe that the most powerful way to live is in the present, dealing with each moment and situation effectively, then it follows that excessive mental energy spent remembering the good old days or the bad old days is not available to use in the present, where everything is happening. Mental energy expended in fantasies of other circumstances and other places also takes energy from dealing effectively with the present. These are all varieties of neuroses for which mindfulness training can sometimes be effective. Here is a simple clinical illustration of how mindfulness techniques can be used with a client.
A 23–year-old, newly divorced female patient complained that her thoughts about her former husband’s bizarre sexual demands were triggering bouts of depression and severe anxiety attacks. She was trained to observe these retrospective thoughts carefully, using Satipaṭṭhāna techniques, and to label them as “remembering, remembering.” Within a few days, she reported that while there was no significant decrease in the frequency of the thoughts, the way they affected her had changed. The labelling process helped her to break the causative relationship between these thoughts and the depression and anxiety attacks, thus allowing the gradual disappearance of those symptoms. What remained at that point were regret about the past and considerable guilt, which were worked on in a traditional group psychotherapy setting in the following weeks.
When straightforward breath observation techniques are used with clinical patients, many potentially positive benefits can be gained, one of which involves what we shall call the “watcher self.” This is the aspect of one’s mental “self” which is discovered through, and carries out, the task of mindfulness. It is the part capable of consciously watching and naming interruptions or bothersome mental habits and events. While it is only one aspect of the total personality, the “watcher” can be useful and important for certain clients because it always behaves with calm strength. The watcher can see the remembering of some painful event and label it objectively without becoming involved in its melodrama. The watcher can therefore put psychological distance between the “me” who experienced the painful event and the “me” who is presently remembering it. The watcher is neutral and can be identified with intentionally. The individual who feels weak, inadequate, indecisive, and defeated can, by intentionally identifying for a time with this watcher, develop new strengths, motivations, and abilities to participate more fully in and benefit from an overall psychotherapy programme. Here is a case in point.
A 27–year-old divorced woman had been hospitalised for two and a half months for a condition variously diagnosed as manic-depressive psychosis, and schizophrenia. She had responded to psychotropic medication to the extent that she was able to begin group psychotherapy free of psychotic symptoms. However, she still suffered from recurring episodes of depression, anxiety, loss of interest in life, and loss of self-esteem. Several weeks of intensive group psychotherapy failed to produce symptom relief, and she was re-admitted to the hospital suffering from severe depression and thoughts of self-destruction. Her primary concerns, in addition to feelings of depression, were loss of concentration and racing thoughts.
Mindfulness technique was presented to the patient as a “concentration exercise.” She was asked to sit quietly, look at the second hand of an electric clock, and try to attend fully to its movement. She was instructed to notice carefully when she lost her concentration on the moving second hand, to identify what constituted the interruption, and to name it. She quickly found her concentration constantly broken by thoughts. On inspection, the nature of the thoughts racing through her mind was always the same—concern with her past, her misfortunes in the relationship with her ex-husband, and her regrets about that situation.
She was instructed simply to label such thoughts, “remembering, remembering.” The labelling process seemed to allow her to withdraw some of her involvement in those depressing thoughts about the past and to let her realise that more than just these thoughts was present in her mind; there was also a “she” who could watch and name thoughts. She learned to identify herself as the objective watcher of her disturbing thoughts instead of the depressed thinker, and she began to feel some relief from her psychiatric complaints.
On reflection, the patient reported that, as a result of this psychotherapeutic endeavour, she had come to see more clearly the nature of her former illness. She subjectively perceived that she had become totally immersed in thoughts and regrets about the past, thus becoming less involved in what was happening around her in the present. She consequently lost any involvement in her future as well. Because her thoughts of the past caused her discomfort and depression, even anxiety, she used large amounts of energy to defend herself against them and make them go away. She felt that during her illness all of her energies had been consumed in thinking about the past and simultaneously fighting to stop such thoughts. This left her no energy to run her life. The mindfulness technique of labelling was effective here because it allowed the patient to stop expending energy in fighting the remembering.
After only a few days of using the exercise, the patient reported a significant increase in her concentration span. This increased concentration, accompanied by decreases in frequency and intensity of disturbing thoughts, allowed her to begin reading again, to carry on meaningful personal interchanges without the usual loss of what was happening, and to devote more time and energy to her personal appearance, which had been untidy during her illness.
With the additional benefits coming from the slightly disguised Satipaṭṭhāna techniques, she could then investigate the nature of the “watcher self” which she had come to identify. This allowed her to come in contact with the calm and peaceful aspects of her own mind—her “centre” was how she identified it at the time—and to re-establish some enjoyment and pleasure in her life. These dimensions had been missing for many months, and this, too, helped with her interpersonal relationships. Within a few weeks of these observations, she was able to decide to terminate therapy, after which she moved to another city, where she intended to begin a new life.
All of the “selves”, “I’s”, and “me’s”, including the neutral “watcher,” are of course the products of continuous brain processes. All of these selves are collectively termed the “ego” in Buddhist psychology (not to be confused with Freud’s use of “ego”). When we employ mindfulness meditation with clinical patients, it is not our purpose to establish the watcher as anything permanent or “real.” The watcher is used only as a tool for grounding some of the patient’s mental energies in the present, providing a temporary, psychologically stable centre for them to operate from and providing a perspective from which their own psychological functioning can be objectively observed.
Many clinical patients, especially those we would label depressive, anxious, or neurotic, have problems either contacting or controlling emotions. Continued work with mindfulness techniques often yields results in these areas, because emotions and emotional states can be made the object of contemplation. Emotions, too, can be watched and labelled (anger, joy, fear), and when seen objectively, they can be allowed to return to their proper place within a healthier psychological system.
During a group therapy session, a 22–year-old married woman who suffered from what had been diagnosed as an endogenous depression expressed despair at her inability to “feel anything anymore,” relating a total lack of emotion. The only feeling she could identify was one of gloom and depression. She was asked to begin to get in touch with her feelings, becoming more aware of, and carefully and accurately labelling any emotion she experienced as she sat quietly watching her breathing or even during her normal daily activities.
Over the next few weeks she found herself increasingly naming anger as her predominant emotion, and it became possible to identify the source of that anger in her marital relationship. She then gradually became aware that she had been misinterpreting her emotions over many months, mistakenly believing that she had been experiencing depression whereas strong elements of anger, hostility, self-abasement, and disappointment had also been present. This recognition of the feelings she had been inaccurately labelling depression freed her to identify other feelings as well. Soon she was back in touch with the full spectrum of human emotions. Her depression disappeared and was replaced by a greatly improved self-image and understanding of her feelings.
In a similar way, thoughts, intentions, and even the task in which one is involved can be made the objects of contemplation within the psychotherapeutic setting, yielding insights into psychological processes that can be useful in helping the patient to grow in positive directions.
A devout Mormon woman of 29, who was married to a teacher, spent her days at home with her two children: At the beginning of their marriage, both she and her husband had been university students, but soon she quit to take a job. After her husband received his degree, they moved to a city where he had been offered a job, and she did not finish her studies. The husband went out to work each day, and she became a housewife. After only a few years of marriage, a definitely unhealthy pattern emerged in their relationship, the husband becoming more involved in his job and spending more and more time there. In fact, job and church activities left him little time or energy for his wife and family.
She began to suffer the classic symptoms of “housewife’s syndrome.” She became depressed, edgy, anxious, and had no motivation or energy to care for the children or to do housework. She ceased going out because she felt even more anxiety outside her home. She could not even sit completely through a church service because her anxiety level would increase until she had to flee, usually using her youngest child as an excuse. At home, she could make no decisions of her own, did not want to be left alone with the children, and berated her husband when he went out for any reason. During the day she just sat, not even watching television or listening to the radio, unable even to bring herself to do simple tasks like dishwashing. At the urging of her husband and mother, she finally came under the care of a psychiatrist who placed her in a psychiatric unit. As was that psychiatrist’s custom, the patient was referred to group therapy immediately upon admission. She also received psychotropic medication and individual daily sessions with ward staff and her physician. In the group she proved to be remarkably intelligent, verbal, and supportive of others’ but initially totally lacking in insight into her own life. She was consistently whiny and often weepy when interacting with ward staff and other patients. After a few group sessions in which she was able to describe her problems as she saw them, and after a session with her and her husband alone in which the family dynamics were well delineated, the therapist decided to use some mindfulness techniques as a supplement to her therapy programme. This proved initially difficult. She rebelled against any kind of introspection because it tended to raise her anxiety level. The therapist finally had her imagine she was back home, prior to hospitalisation, just sitting during the day as she often had done. Then she was asked to look at the thoughts which had been taking place there and to attempt to relate them to the therapist. Although she accomplished the task with some difficulty, it became quite evident over time that her predominant mental process was imagining. She used all kinds of fantasies to take her away from her anxieties and depression and poured great amounts of energy into that process.
Though we had not established the watcher through the usual set of mindfulness procedures, we had discovered the patient’s main interrupting factor. It was then pointed out to her that she was using most of her energies in fantasising, and she could easily see this. She was then told she would have to work on this if her problems were to be alleviated. Though she expected some mysterious psychological procedure to accomplish such a thing, she was, in fact, instructed to bake a cake mindfully in the treatment centre kitchen, trying to attend fully to every detail, to notice when she began to fantasise and to return to full concentration on the task. She did this and found that she could use some of her energies in a present-oriented task, observing when she was interrupted by the persistent fantasies.
A substitute for breath observation, the cake baking routine was used as an example of how she could attempt to attend fully to the present moment, no matter what was happening. She began to work hard at this and slowly improved. She had a mechanism for noticing when fantasies began, and she found that they were decreasing in length and frequency. She could intentionally return to the present, and she learned that, with this intention, she could initiate behaviours, such as cooking, sewing, reading, and piano playing, which she had neglected for some time. She played the piano very well at the treatment centre and found music an excellent way to stay grounded in the present.
In group therapy, she worked on relationships between herself and her husband. This was supplemented by family therapy sessions in which he participated fully.
She also worked on her extremely dependent relationship with her mother who constantly told her what to do; she gained independence and confidence, slowly losing her anxieties. She continued group and family therapy for several months after which she was released from hospital. During that time she began to attend church without anxiety, to care for the house and children, and to get out and involve herself in activities that interested her and helped her grow. Although the mindfulness techniques were not the only psychotherapeutic tools employed, and perhaps were not even the primary ones that aided her, they proved to be the key approach in getting her moving and growing in a positive way again.
A psychotherapist-as-guru approach is not being advocated here. Neither is sending the client to meditate advocated as the best therapy. The word meditation is seldom mentioned to patients. What is being advocated is the adaptation of certain useful techniques of mindfulness meditation to the treatment programme for selected clients. Mindfulness training does not work for everyone. To look directly within requires a great effort, and psychotherapists realise that many clients, particularly those just beginning therapy, are not capable of this kind of intense work. As I have pointed out before, mindfulness training is most appropriate for clients with an intact rational component and sufficient motivation to make the effort required. Only with these two factors present will the techniques be successful.
In short-term psychotherapy, breath-observation techniques, or some:modification of them, are usually most appropriate. Discussion between client and therapist about insights gained is the primary indicator of the techniques’ effectiveness for a given client. In long-term applications of mindfulness techniques, basic breath observation and interruption naming are first accomplished. Then the client can observe mental processes during everyday activities without needing breath observation as the focal point. Emotions, thoughts, and thought subject matter can be observed in any life situation once the watcher is trained. Awareness is then focused directly on what is happening in the present and on the mental processes of perceiving and reacting to external and internal stimuli which are gaining access to consciousness. Insights into the perceptive process—how external events are translated into internal reality—seem to occur if the “meditation” is directed toward seeing the external situation clearly and objectively from the perspective of the watcher self, which does not react emotionally, verbally, or behaviorally but simply sees. The watcher can suddenly see old and persistent patterns of reacting to certain standard problem situations. This frees the client to respond volitionally in new and different ways. The automatic response of fear or anger to a particular set of stimuli—an authority figure perhaps or a frustrating situation—will suddenly be seen occurring, due to concentration on the incoming stimuli of the present moment. These can be valuable, insightful occurrences for the individual who goes to the trouble of practising and refining the mindfulness techniques. A simple, non-clinical example illustrates this.
If I am driving during rush hour, a dangerous near collision with another car can be a good situation to observe mindfully. The near collision may have been due to the failure of a traffic light, rather than either driver. Yet the other driver directs abuse at me. The other driver’s statement is an event external to “me.” If I am being mindful, “I” will note that “I” perceive the event in a particular way, namely that the other driver is being unfair and unjust. This perception of the event leads to an immediate intention to reply, to assert “my” point of view. There is great freedom available to me when I see that intention clearly, because many possibilities exist for action or inaction. If I do not see the intention and resultant emotions, like anger and frustration early, I can only react to the situation instead of experiencing its freedom. Seeing the intentional process arising allows a choice of responses: verbal action (“The same to you, fellow!”), physical action (crashing my car into his to teach him a lesson), early cancellation of either the verbal or physical action, thinking vindictive thoughts about the other driver; it even allows for the continuation of mindfulness—operating in the present, continuing to drive mindfully, and letting the negative thoughts and emotions produced by the event dissipate, instead of preserving them in my consciousness and going over and over them in memory. It does not matter whether I choose thoughts, words, actions, or cancellations as long as these things are done at a level of awareness where I can suddenly come to understand and say, “Oh yes, now I see why I always do that.” These are everyday insights that come with increased mindfulness.
Mindfulness training, then, can create a space between life’s events and the ego’s reaction to those events. The ego itself begins to be seen and known. Mental processes basic to the ego are sometimes seen in operation. Slowly one becomes capable of dealing more effectively and intelligently with each life event as it occurs. At this stage of development, the watcher’s role begins to shift and diminish. Occasional, total conscious immersion in present events begins to occur without the watcher consciously watching. In this state of total involvement, no mental energy is held back for consciously operating the watcher, and none is used to escape in fantasies or memories; one is functioning at heightened effectiveness. Emotions associated with total involvement are purer. They are uncontaminated by reactions to involuntary memories and fantasies typically projected onto ongoing situations. A state of mental health without the neurotic internal mental dialogue’s constant comments and digressions has been temporarily achieved. Total concentration is directed to the task at hand, whether it be washing the dishes; solving a family disagreement, or driving to work. For a time all the “I’s” and “me’s” are quieted, and the whole person, with all capabilities intact, is allowed to function.
The goal of mindfulness training, then, is to work directly with the ongoing train of experiences, to practise directing “bare attention” to those experiences, to develop patience with and compassion for oneself as well as others, and to deal effectively with neurotic disturbances of mind. This, of course, is asking a great deal. Many clients find it difficult, painful, and even overwhelming to look at their own troublesome and persistent mental processes. A greatly agitated, depressed, or otherwise disturbed individual is not an immediate candidate for such direct therapy, although he or she may later derive great benefit from this approach.
The following case study demonstrates the use of mindfulness techniques with a woman in long-term therapy.
A 27–year-old woman, married with two young children, was referred by her psychiatrist for group therapy because of increasing depression and inability to cope with family and life responsibilities. She was an intelligent, beautiful woman who was cool and aloof in interpersonal relationships. She attended group therapy for a few sessions and identified some problems with her husband, who travelled extensively and was away from home on business four or five nights each week. She suspected he was being unfaithful, and he admitted he had had an affair a few weeks earlier with a woman in another city.
After about her third week of group therapy, I received a frantic call from her husband one morning saying she had attempted suicide by overdosing with sleeping pills. She was comatose and in the intensive care unit of the hospital at that time. While we waited for her to regain consciousness, the husband related his understanding of the family problems and stated that the attempted suicide had resulted from his wife’s reduced sense of self-worth because of his confessing to the affair. He felt guilty about it, vowed to quit the job, and began to search for another that day.
As she awoke, the woman was upset to learn she had failed in her suicide attempt, and repeatedly said she wanted to die. However, on later learning her behaviour had caused serious reconsiderations on her husband’s part, she soon agreed to a no-suicide contract and was transferred to the psychiatric ward by her physician. Her temporary but apparently sincere agreement to remain alive left her with little choice but attempt resolution of the conflicts which had brought her to this point.
Although she was still unable to express herself openly in group therapy and soon even refused to attend the group, she proved a willing and capable client in an individual setting. So all subsequent work with her was on a one-to-one basis. She received the usual psychotropic medication for approximately two weeks while in the hospital. She finally admitted in a private session that she had been experiencing strong feelings of friendship, warmth, and perhaps even sexual attraction for an older woman whom she had met a few months earlier. The woman was outgoing, artistic, and in the client’s view, everything she was not. She felt guilty and even abnormal about these unwanted feelings. We were able to make some progress in helping her to accept, understand, and work with those feelings during the first days of her hospitalisation.
Before leaving the hospital, she began the basic mindfulness practices of thought and feeling observation. She found no difficulty in thought observation because she was a persistent intellectualizer. However, she claimed to be able to identify no feelings at all. Over some weeks after leaving the hospital, she began to identify two feelings. These were not identified during breath observation but only during situations which arose during the day. She was able to identify strong anger at her husband and children at times and fear in certain interpersonal situations, particularly in meeting male strangers in new social settings. She worked hard on the social fear and soon lost much of her former aloofness by consciously trying to be open, attentive, and receptive in social encounters. At that point, with her depression alleviated and some of her problems partly solved, she chose to terminate therapy. She had not yet really looked at her barely repressed homosexual desires toward her friend.
Approximately one year later, she came to my office saying she felt minor recurrences of her old depression and was afraid. In talking with her, I learned that with her husband home each night, her marriage had slightly improved but was still less than perfect. The friendship with the older woman had developed into a sexual relationship, and she was again feeling guilty about it.
She specifically requested that we continue the mindfulness training she had begun months before. This time we worked, not on breath observation, but on increasing awareness during ordinary life events, especially in stressful situations. She progressed rapidly, finding that her social fears produced a characteristic response of coldness and near withdrawal, which made her seem conceited to others. She was able to see this mechanism coming into play, and thus to stop withdrawing. She began to derive some of the fulfilment from social situations previously denied her, and to accept more fully the bisexual nature of her sexual relationships. Although this channelled some of her energies away from her marriage, she seemed to have more satisfaction from both relationships.
This woman has come to feel very positive about herself; her occasional minor bouts of depression ended, and she has remained apparently symptom-free for a year. Since her hospitalisation, she has coped well at home, has grown greatly in personal satisfaction, and has completed two years at the university, something she had previously wanted to do but never felt capable of doing. No further suicide attempts or serious depressions have occurred to date.
This case study is fairly typical of long-term employment of mindfulness training. It takes months, even years, for most of us to grow out of psychological difficulty. It takes persistent application of the techniques to ensure growth, and each person has to grow at his or her own pace. If there is time available, if the therapist can provide the appropriate guidance, and if the client has the motivation and perseverance to work through problems, only then can the mindfulness approach be considered appropriate for a client.
Mindfulness meditation techniques, when used in psychotherapy, have several things to offer the psychotherapist. First of all, the approach is very client-centred; it allows the client the freedom and dignity to work with himself under the therapist’s guidance. This, of course, is efficient because it does not confine therapy to the hours when therapist and client meet. Also, it does not condition, direct, or shape the client’s behaviour into some preordained pattern decided by the therapist. Instead, the course of therapy is more one of the client’s seeing, knowing, and accepting his mental processes and then allowing them to re-form and grow in new ways that are healthy for him. However, it is not a cure-all as is shown in this case.
A slightly disguised set of satipaṭṭhāna techniques was employed with a 23–year-old male patient who had been hospitalised for extreme periodic aggressiveness, fighting, and alcohol abuse, which had occasionally led to brief periods of amnesial or fugue-like states. This young man, who was married and had young children, had been extremely irritable and explosive at home, often losing his temper over minor events and striking out physically or storming out of the house for up to three days. A typical though infrequent pattern was for him to go to a bar with friends for a few drinks during the evening and become intoxicated. In this condition he would often steal a car, get in a fight, or even threaten homicide, but he failed to have any memory of these acts the next day. He was hospitalised twice after such unlawful behaviour.
The second time he was admitted to the psychiatric unit, he proved warm and cooperative but experienced high anxiety levels when the staff wanted to discuss why he was in the hospital. He chose to characterise himself as an alcoholic. After a few days of psychotropic medication, his psychiatrist referred him for group therapy. For the next few weeks, he received a therapeutic programme consisting of brief daily visits by the psychiatrist, psychotropic medication, twice-weekly group therapy, a weekly session of conjoint family therapy with the group therapist, and whatever sessions the patient chose to initiate with the psychiatric nursing staff. This programme was continued throughout his four weeks in the hospital and four more of outpatient care.
During the initial group and family therapy sessions, numerous identifiable marital problems became evident; these were the focus of the family therapy. Group and individual therapy revealed personal problems of expressing anger, self-image, hostility toward women, and extreme competitiveness with other men.
Since it did not appear that this man would be receptive to the usual mindfulness approach, a modified version was tried. His tendency to deny anger and then express it explosively seemed to be a good place to begin. It was mentioned casually during a group therapy session, when the topic arose naturally, that one could perhaps come to know, quite accurately, the causes of one’s behaviour. The young man took issue with this, saying he did many things he could not hope to understand. It was suggested that he attempt to look at and name the emotions he experienced during the next few days. He tried that suggestion and reported that what he felt most of the time was fear (of people or sometimes of nothing he could identify) and psychological pain. He was instructed to keep watching and naming emotions. Over some weeks, he began to see anger arising in certain interpersonal situations. He was also able to experience his feelings of irritability and to see what events produced them. Most important, he began to be aware that he did not express anger and often was not even cognizant of it until it had overwhelmed him. He was taught to verbalise his anger, to vent it as he experienced it, and to view anger as something all people normally feel. This seemed to free him for progress in psychotherapy. He stopped seeing his problem as alcoholism and spoke of alcohol intoxication as another way of trying to hide from his anger. Soon he stopped mentioning alcohol at all.
Other mindfulness techniques were then used with this man, particularly thought contemplation, which made him aware of his ineffective and inaccurate self-image. This helped him to start correcting misunderstandings about male-female relationships. At the end of eight weeks of this treatment, he took a job. Ten months later, he was still functioning effectively at home and at work, with no recurrences of drinking, fighting, or fugue-states. The mindfulness techniques used here constituted one part of an overall therapy programme which proved to be effective.
A few months after this case history was published, the man again behaved erratically. Even at the behest of his family and friends, he refused to seek help and continued to encounter more problems, primarily with his family and his job. He finally fired a rifle through the window of a house, critically injuring a woman he did not know while apparently trying to injure his wife. At this writing, he is confined awaiting trial.
This case is an isolated but a striking example of a person who did not continue to grow after terminating therapy, but instead slowly lost the benefits he had gained. The psychotherapeutic gains achieved through the use of this technique, like most other forms of therapy, can erode over time if the client ceases to practise mindfulness and stops growing. It is usually a mistake to expect predictable, linear progression through therapy for a patient using mindfulness techniques, as the following case demonstrates.
A 21–year-old female sought help for her increasingly frequent anxiety attacks. Although the attacks could come upon her at any time, she was particularly troubled by crowded places such as classrooms. Her case was complicated by her having been previously treated unsuccessfully by two other psychotherapists. One had apparently attempted desensitisation procedures, treating her case as a phobic reaction to crowded places; the other had served only as a counsellor discussing her problems with her. Both had failed to alleviate the symptom, and she had terminated therapy after a few months in each case.
After some preliminary sessions, we decided to try mindfulness techniques. She was shown the basic breath observation technique of noting interruptions and naming them. After this, most sessions consisted of discussing her experiences with the mindfulness practices. After she had become fairly adept at noting and naming interruptions to breath observation, and after the watcher had been investigated, she began to work on observing emotions. She reported that, as she sat quietly observing interruptions and emotions, fear would arise within her from no detectable source, panic would follow, and she would then have to struggle with that anxiety—effectively ending her observation as she became involved with the anxiety. Slowly she became aware that the watcher could see but did not experience anxiety, and she could sometimes get a little space between the “me” who was so afraid and the watcher.
Suddenly unexpected progress began to occur in our sessions together, progress that seemed to have been impelled by the mindfulness training. The case became almost classically psychoanalytic for a time, with our discussions proceeding backward in time to the point where she discussed a sexual experience with an aggressive older boy when she was 12. From that almost cathartic session, other sessions followed in which she discussed a long period of sexual promiscuity. At that point in therapy, her crowd-induced anxiety attacks began to subside, allowing her to go into places which had been previously troublesome. Then she related in great detail a long-repressed incident that she had mentioned slightly in one of our first sessions. When she was 9 or 10, her father had—at least in her perception of the event—attempted to seduce her. Telling her mother about the incident had caused family difficulties, and she had incurred much guilt about her parents’ relationship. All of this poured out as well as her hostility towards males. All her later life had been concerned with rewarding, punishing, and controlling males with her sexuality; at last she began to see this important fact.
By this time her anxiety attacks had grown infrequent and were far less terrifying mainly because she was able to experience them more from the watcher’s point of view. The attacks tended to occur only when she was alone, and she felt more capable of dealing with them. Her therapy was finally terminated when she and her husband moved to another city, where she apparently continued with another therapist.
The mindfulness approach to psychotherapy has proven to be compatible with chemotherapies, somatotherapies, and various other psychotherapies. It can provide valuable and timely insights for most clients with whom it is used appropriately, insights that can be deepened and broadened through discussion as therapy progresses.
However, the clinician who plans to use this approach needs first to become personally familiar with the technique. He or she should verify the insights potentially available by practising the techniques personally before employing them with clients.
People almost never seem to reach a condition of total psychological stability. Change is constantly required of us as we age and encounter new experiences. Mindfulness training can help the client to continue to adapt successfully long after formal therapy has ended.
Mahāsi Sayādaw, The Satipaṭṭhāna Vipassanā Meditation. San Francisco: Unity Press, 1972.
Nyanaponika Thera, The Heart of Buddhist Meditation. New York: Samuel Weiser, 1973.
Nyanaponika Thera, The Power of Mindfulness, Santa Cruz, Unity Press, 1972. 
Soma Thera, The Way of Mindfulness. Kandy: Buddhist Publication Society, 1975.