Over the past two decades, much has been said about the nature, mechanisms and roles of mindfulness. Yet, some conceptualisations and their derived clinical packages display an obvious lack of differentiation between mindfulness, awareness and attention. Here, Dr Bruno Cayoun, director of MiCBT Institute in Hobart, shows clinicians how to develop, study and teach mindfulness.
Most of us have read or heard that mindfulness involves paying attention on purpose, in the present moment and non-judgementally (Kabat-Zinn, 1990). Although elegant in its economy, this definition has led to erroneous interpretations and methods far enough removed from the original meaning to make the Buddha weep if he were alive today. Anything goes, from paying attention to the flowers in your backyard to paddling on your surfboard…and why not learn mindfulness from your dog? Indeed, there is so much confusion and unintentional abuse of the word that many well-intended newcomers to mindfulness are often limited to engage in a process of relaxation, where group sessions often turn into a snoring camp.
So what is mindfulness? If it were simply to pay attention on purpose, in the present moment and non-judgementally, then a cat waiting in front of a mouse hole, ready to jump on his prey, would be a mindful cat. A sniper paying purposeful attention in the present moment, ready to shoot, not judging his action or the orders he received, would also be a mindful sniper. Could shooting people professionally lead to a mindful life? To gain a better understanding of the true meaning of mindfulness in the context evoked by the traditional teachers over the past 2,500 years, it may be useful to examine its original purpose.
When Siddhartha Gautama, better known as the Buddha, realised that no ritual, belief or self-harming exercise (including starving himself) could lead him to the ultimate liberation from the common suffering of human life, he decided to simply observe the nature and functions of his mental and physical experiences, hoping he would understand the causes and effects of human phenomena.
Much as a modern researcher in the field of phenomenology, he embarked on a journey of studying mind and body, and how emotions emerge from the combination of the two. His only tool of investigation was his attention, but used in a very specific way, a way that is unbiased by the observer, an impersonal (‘egoless’) way.
Having achieved his goal, he taught monks, nuns and householders for the following 45 years how to do the same through their own effort. He taught that freedom from suffering can be achieved by everyone who develops a sufficient amount of wisdom through the cultivation of mindfulness. Accordingly, mindfulness has since been taught as a means to an end, rather than an end in itself. When understood in this way, it is a tool of self-investigation, a path to a destination, rather than the destination itself.
In science, especially phenomenology, not identifying with the object of observation is a crucial prerequisite for examining phenomena in the most objective way. Moreover, the observation needs to be sustained and free from reactivity. A reaction to what is being experienced can only occur when we take things personally, whether it is a memory spontaneously emerging in consciousness or physical pain due to sitting in meditation. In contrast, when unbiased observation is accompanied by equanimity (non-reactivity), we can observe phenomena more as they are – to the extent that human perception allows – and learn the most fundamental laws of nature.
One such law is the impermanence of all things, including our sense of self. When our attentiveness is untainted by expectations and reactivity, we can witness thoughts and physical sensations mindfully, in terms of transient and impersonal phenomena, keeping our mind peaceful, patient, tolerant and interested. The more we realise that our troubles, past and present, are also of impermanent nature, we don’t dwell on them. We prevent ruminating, catastrophising or taking things personally in any other way. We are progressively able to let go because our first-hand experience serves as cognitive reappraisal. We realise that even worse-case scenarios will also pass.
Hence, seeing things the way they are, rather than through the lens of our personality, culture, autobiographical memories, schemas and needs, opens our eyes to what is important. Knowing the time and place to perform an action, remaining ethical to prevent harm to oneself and others out of compassion, and letting go of our attachment to things since all are impermanent, including our image, are examples of how wisdom is expressed.
Mindfulness has been taught for 25 centuries for this very purpose. Far from being a ‘new-age bubble’, it is the mental effort to maintain awareness of our experience as it unfolds from moment to moment without identifying with any aspect of it. This is called ‘right mindfulness’ (sama sati in Pali) in the Great Discourse on the Establishment of Mindfulness (Satipatthana Sutta) (Vipassana Research Institute, 1996).
As a consequence of becoming more mindful and equanimous, our emotional reactivity decreases in duration. This traditional marker of successful application of mindfulness is supported by a measurable decrease in the right basolateral amygdala following eight weeks of mindfulness meditation (Hölzel et al., 2010). As we become more experienced, peak intensity of reactivity also decreases, even in the presence of distressing chronic pain (Cayoun, Simons, & Shires, 2016). We become increasingly aware that reactivity is but a reflection of our unawareness or forgetfulness that the object of reactivity is also impermanent.
In its traditional context, mindfulness is taught carefully across four domains of experience: mindfulness of body (kayanupassana), mindfulness of body sensations (vedananupassana), mindfulness of mental states (such as emotions; cittanupassana), and mindfulness of mental content (thought, images and so on; dhammanupassana) (Analayo, 2003). It should not be limited to the breath, as it often is in the West, and the main purpose is to investigate the omnipresent reality of impermanence at these four experiential dimensions. The result is an increased cognitive flexibility (Cayoun, 2015), reflected by a progressive detachment from the notion of a permanent self, which in turns creates a sense that we can change if we so choose.
Accordingly, paying attention in a way that allows craving, aversion or identification with the experience to proliferate is clearly not mindfulness (Brewer et al., 2011). It may be paying attention in the present moment, but not in a way that frees one from emotional suffering. This is not to say that paying simple attention to what we do, think or feel is not useful. On the contrary, it is a good vehicle for mindfulness and it might be relaxing as we distract our mind from aversive experiences.
However, whereas attention is the mental effort component of mindfulness and awareness the recognition aspect of mindfulness, both lack what is conducive to wisdom. They lack objectivity and detachment. Mindfulness requires a selfless observation of phenomena that is free from value-based evaluation and is accompanied by equanimity, which is sometimes equated with ‘acceptance’, but is more precisely “an even-minded mental state or dispositional tendency toward all experiences or objects, regardless of their affective valence (pleasant, unpleasant or neutral) or source” (Desbordes et al., 2015, p. 357). An equanimous mind is unperturbed by the experience it perceives. In contrast, we can be aware in the present moment while being emotionally reactive, which is markedly different to a mindful mental state. Accordingly, it is inaccurate and misleading to use the term mindfulness to describe what is simply focused attention.
Let us now apply this understanding to training, therapy and research. Some authors have proposed several mechanisms of action (e.g., Bishop et al., 2004; Cayoun, 2011; Grabovac, Lau, & Willett, 2011; Lau & McMain, 2005), from which we can extract that exposure is the principal mechanism during mindfulness meditation. For instance, during the practice of mindfulness of breath (anapanasati), attention is typically focused and maintained at the entrance of the nostrils, using the breath as an anchor. Sustaining attention in this way allows us to detect spontaneously emerging stimuli, such as thoughts and images, while maintaining a neutral, equanimous attitude. Similarly, when practising mindfulness of body sensations (vipassanā), attention is passed systematically through the entire body while feeling and accepting what is or is not being felt. Surveying (“scanning”) the body in this way allows us to feel whatever we come across while remaining equanimous – that is, preventing learned responses (craving for pleasant experiences and resenting or avoiding unpleasant ones).
From a behavioural perspective, this has been operationalised as a generalised interoceptive exposure and response prevention method (Cayoun, 2011). Every time we prevent an aversive reaction (for example, avoidance) while exposed to an unpleasant experience, or prevent a craving reaction (attachment) while exposed to a pleasant experience, our learned response is weakened and progressively extinguished, as recently demonstrated through neuroimaging research (Hölzel et al., 2016).
One of the consequences of assuming that attention in the present moment equates to mindfulness is frequently observable when your client faces a distressing situation. While being anxious, insufficiently educated clients will often use the breath as a distraction from the interoceptive feedback (for example, unpleasant visceral body sensation), assuming they used their mindfulness training. How often do we hear, “You will be proud of me, I was just about to have a panic attack and I went straight to my breath, and it calmed me right down”
In such a case, two mechanisms are at work: distraction and avoidance of unpleasant bodily cues. If the client remains with this approach to handle high arousal states, they are not getting any closer to experiential awareness and acceptance. Their ability to remain equanimous and realise how discomfort is indeed impermanent is not developing. They may be more relaxed, but certainly not desensitised. We are just scratching the surface, so to speak, and far from the intended wisdom.
As an exposure method, mindfulness requires conscious attention, ideally produced by formal meditation. During mindfulness meditation, we sit immobile in silence and eyes closed, not stimulating the sense of sight, touch, taste or smell, and preventing automatic thinking. This allows all irrelevant sensory functions to rest while attention resources are reallocated to the relevant ones; metacognitive and interoceptive functions. To this end, executive functions are recruited (Doll et al., 2015) for sustaining attention, inhibiting the unhelpful responses, and switching attention back to the target (breath or body part) as soon as attention has been distracted. These cause a decreased activation in neurological correlates of self-referential processing and stress (especially in the amygdala and medial prefrontal cortex) and an increased activation in our ability to detect thoughts and body sensations without identifying with them (anterior cingulate, lateral prefrontal, somatosensory and insular cortices) (Farb, Anderson, & Segal, 2012; Hölzel et al., 2011; Lazar et al., 2005).
While these brain areas have been reliably shown to change in volume during mindfulness meditation, such brain reorganisation has not been demonstrated when formal meditation is not practised (Ivanovski et al., 2006). This may be because trying to practise mindfulness in daily life, outside the meditative context, also engages other sensory processing needing our attention. We are continually exposed to necessary mental and physical operations that distract us from subtler experiences that would otherwise be conscious in the dedicated context of meditation. In daily life, most of what is subconscious remains subconscious, including our propensity to react emotionally. With divided attention and lack of equanimity, there is far less possibility of detecting early cues of distress before they develop into full-fledged emotions that become too overwhelming for one to prevent reactivity.
This leads us to consider the differential effects of formal meditation practice and the attempt to be mindful without it. Can we develop mindfulness without meditating, as it is sometimes proposed? Applying mindfulness skills in daily life is definitely recommended, and is most beneficial if it is coupled with, or has been learned through, formal meditation (Fallon, 2013).
However, without formal practice, the lack of neuroplasticity renders the skills over-reliant on a top-down effort, where one must remember to be mindful. Paradoxically, automaticity in the mechanisms of emotion regulation is also a consequence of accurate mindfulness practice. ‘Letting go’ becomes increasingly easy and plays an important role in the prevention of relapse (Segal, Teasdale & Williams, 2002). Without such rewiring in corticolimbic networks, learning remains fragile in the face of elevated distress and effort to continually remind ourselves to stay in the present is necessary, yet not always possible, when distress is pronounced. There is evidence that the less we practise mindfulness in formal meditation, the less skilled our brain is in coping with ruminative brooding (Hawley et al., 2014).
Thus, as the inclusion of mindfulness in clinical interventions is continually gaining popularity, there is an important differentiation to be made between mindfulness, awareness and attention, as their use in therapy may have differential effects on mental health clients. Since claims that mindfulness can be developed without meditative practices are not substantiated by neurological evidence, methods guided by this view are likely to limit their intervention to using attentional tasks, rather than mindfulness. Even though simply paying attention to the task at hand is skilful and clinically beneficial, as shown by its use in traditional cognitive and behavioural methods, it is not directly conducive to the expected mindfulness-related skill set, especially relapse prevention.
We are very fortunate to live in a time when mindfulness is a sought-after approach and no longer perceived as a strange hippie or sectarian practice. The research evidence in both behavioural science and cognitive neuroscience is abundant and strong, which is now a great asset in discerning mechanisms such as those discussed in this article. It is hoped that our hurried lives and fast-food culture will not succumb to misleading marketing, which plays on our temptation to learn quickly, cheaply and without much effort.
Clinicians genuinely interested in developing mindfulness skills personally or professionally may consider learning them through formal mindfulness meditation, after carefully verifying the lineage and training of their potential teachers, and the teachers who taught them. Well-informed mindfulness researchers are also more likely to obtain clearer data and produce more meaningful research if the variables measured are consistent with the construct of mindfulness.
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Dr Bruno Cayoun is a clinical psychologist working in private practice and director of the MiCBT Institute in Hobart. He is the principal developer of Mindfulness-integrated Cognitive Behaviour Therapy (MiCBT) and has been teaching this approach to mental health professionals internationally since 2003. He has practised mindfulness meditation and undergone intensive training in mindfulness centres in France, Nepal, India and Australia since 1989.