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Integration of Dynamic Psychotherapy and Mindfulness Development

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Integration of Dynamic Psychotherapy and Mindfulness Development Review article Integration of dynamic psychotherapy and mindfulness development Chamlong Disayavanish,1 and Primprao Disayavanish1,2 1Department of Psychiatry, Faculty of Medicine, Chiang Mai University, 2Division of Education Administration, Mahamakut Buddhist University, Lanna Campus, Chiang Mai Currently, the integration of mindfulness development or mindfulness-based intervention (MBI) with psychotherapy and its clinical applications is increasing. Clinical practice has combined new psychotherapies with mindfulness development such as mindfulness-based stress reduction (MBSR), acceptance and commitment therapy (ACT), dialectical behavioral therapy (DBT) and mindfulness-based cognitive therapy (MBCT). However, the application of mindfulness to the practice of psychotherapy has been limited mostly to cognitive behavioral therapy. Therefore, the authors of this article would like to introduce the concept of mindfulness-based dynamic psycho- therapy (MBDP), which integrates the practice of mindfulness with dynamic psychotherapy. From a Buddhist viewpoint, attachment to oneself or the fi ve aggregates of attachment (upadan- akkhandha) is the core of human suffering in both physical and mental aspects. During insight meditation (vipassana), the meditator gradually develops not only mindfulness (sati), but also clear comprehension (sampajanna) or wisdom (panna) of oneself, which is a combination of body and mind and subject to the three universal characteristics, namely i) impermanence (anicca), ii) suffering (dukkha), and iii) no ego or non-self (anatta). This experiential wisdom occurs repetitively, and gradually becomes more mature and profound. This process is similar to “working-through” in dynamic psychotherapy and this kind of wisdom or insight at the experiential level can diminish or eradicate the attachment to self, which is the core of suffering. To follow insight in the practice of mediation, the meditator shares his or her merits, metta (loving- kindness), and karuna (compassion) to all sentient beings. Loving-kindness and compassion are effective antidotes for sexual and aggressive drives. Three clinical case reports are presented in order to illustrate the integration techniques of mindfulness development with dynamic psycho- therapy. Chiang Mai Medical Journal 2015;54(4):209-18. Keywords: mindfulness development, insight meditation, dynamic psychotherapy Introduction Psychotherapy is currently in a changing ingly and training in psychotherapy is becoming phase. The contribution of psychological thera- more widespread and systemized. Evidence- pies for the treatment of patients suffering from based practice is replacing methods that mental disorders has been recognized increas- derived from tradition and authority, and new Address correspondence to: Chamlong Disayavanish, M.S., M.D., Department of Psychiatry, Faculty of Medicine,Chiang Mai University, Chiang Mai 50200 Thailand. E-mail:[email protected] Received: September 8, 2015, Accepted: December 16, 2015. 210 Chiang Mai Med J 2015;54(4): psychological treatment techniques are being thorough awareness of the object. pioneered. Much of the new change is integra- Mindfulness has the function of not losing tive, with both a theoretical and practical or not forgetting the object (asammosa rasa). approach[1]. This means that the mind that notes and Integration of psychotherapy with mindful- observes should not lose sight of, miss or for- ness development or mindfulness-based inter- get the object of observation, or allow it to dis- vention (MBI) is becoming more popularity in appear; just as a footballer never loses sight the modern era[2-4]. Clinical practice has com- of the ball. There are two manifestations of bined a number of new therapies with mind- sati, namely confrontation and protection. Sati fulness development such as mindfulness- manifests when the mind is confronted face-to based stress reduction (MBSR)[5], acceptance -face (abhimukha) with an object. If the mind and commitment therapy (ACT)[6], dialectical that notes and observes remains face-to-face behavioral therapy (DBT)[7] and mindfulness- with the object of observation for a signifi cant based cognitive behavioral therapy (MBCT)[8]. period of time, the meditator can experience purity of mind, due to the absence of kilesas Mindfulness-based psychotherapy (mental defi lements). Mental purity is the result of the second manifestation of sati, A number of combined approaches were which acts like a guard at the gate or as the limited to cognitive-behavioral therapy, and protector from attack by the kilesas (arakkha very few studies or researches have been praccupatthana). With mindfulness present, devoted to the integration of psychodynamic mental defi lements have no chance to enter psychotherapy and mindfulness, such as Mind- the stream of consciousness[14]. ful meditation as psychotherapy[9], Thought without a thinker[10], and Going to pieces with- out falling apart[11]. Therefore, the highlight of Five components of the practice this presentation deals with the integration of In the practice of insight meditation (vipas- mindfulness development or insight medita- sana), mindfulness (sati) is not only used tion (vipassana) with dynamic psychotherapy, alone, but also works in combination with which is termed “mindfulness-based dynamic four other components, namely faith (sadda), psychotherapy (MBDP). Mindful meditation effort (viriya), concentration (samadhi) and is based on the Four Foundations of Mindful- clear comprehension (sampajanna) or wisdom ness, namely the body, feeling, mind or con- (panna). Although mindfulness and clear sciousness and mind-object [12,13]. comprehension are two major components, the fi ve factors work simultaneously and har- The meaning of mindfulness moniously with each other. They are called the fi ve mental faculties (indriyas). When in- “Mindfulness” has become accepted in the sight meditation is practiced, balance of effort English translation as “Sati”. Commentaries and concentration is especially important[15]. have defi ned sati as remembering, and its characteristic is said to be “non-wobbling, non- superfi cial or not fl oating on the surface Suffering and mental disorder (apilapana lakhana). Commentators provided The fi rst noble truth of suffering consists of the simile; like a dry, hollow pumpkin thrown birth, aging, disease, death, sorrow, lamenta- into water, and bobbing up and down on the tion, pain, grief, and despair. It also includes surface. On the contrary, when a stone is association with dislikes, separation from thrown into water, it sinks to the bottom where likes, and not getting what one wants. In brief, it stays fi rmly embedded. In the same concept, the fi ve aggregates of attachment (clinging) is sati must not be superfi cial, but plunge deeply the core of suffering[16,17]. into the object of observation[14,15]. Hence, In fact, human suffering must be viewed as mindfulness is not superfi cial, but a deep and diseases, both physical and mental. In terms Disayavanish C, et al. Integration of psychotherapy and mindfulness development 211 of psychodynamics, attachment to self (oneself) awareness of what actually happens to us and or ego is the core of human suffering. Hence, in us at successive moments of perception. the symptoms of mental disorders, such as It is called “bare” because it attends to just anxiety, stress, depression, phobia, obsession, the bare facts of a perception, as presented compulsion, somatic symptoms, restlessness, through either the fi ve physical senses, or mind abnormal aggressive and sexual behavior, that constitutes the sixth sense[22]. In addition, insomnia, delusion, hallucinations and other bare attention also means observing things as factors are the manifestation of self or ego they are without choosing, without comparing, attachment[17,18]. without evaluating and without laying projec- tions and expectations on what is happening, Buddhist approach to treatment of or in other words, without reacting to anything mental disorder that arises at the present moment[23]. Psychologically speaking, bare atten- It is said in the Pali axiom, “Sabbe puthujja- tion is a form of detached observation and can na ummattaka (all worldly or ordinary persons be compared to an “observing ego”, as distin- [18-20] are insane)” , that ummattaka means guished from an experiencing ego in dynamic “madness”, “insanity” or “lunacy”. The actual psychotherapy[24]. When looking at something meaning of ummattaka is similar to the phrase subjectively, there is a mental affi nity between “psychotic disorder” in modern psychology, us and the thing being looked at. This kind of however, in Buddhist psychology ummattaka relationship tends to yield a great deal of infl u- includes not only psychotic disorders, but also ence and colors our relationship. In short, we [20,21] varied mental derangements . are an interested observer. On the contrary, if It is said “Satipatthana can overcome in- we look at something objectively, the relation- sanity”[19,20]. From the Maha Satipatthana ship between ourselves and the object will not Sutta, the Buddha said, “This is the only way infl uence our observation. In this situation we for the purifi cation of being, for the overcoming are bare observers. We even treat our feel- of sorrow and lamentation, for the disappear- ings, thoughts or emotions with bare attention ance of pain and grief, for attaining the Noble by observing them objectively or by misidenti- path and for the realization of Nibbana, name- fying ourselves with
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