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 them[25,26]. ly the Four Foundations of Mindfulness”[12,15]. The practice of insight meditation according to For example, when a thought or anger the Four Foundations of Mindfulness can lead arises, one must be fully aware of this and try to the end of suffering. to observe clearly without identifying with it. Deep and penetrative insight into the rea- The thought or anger is not viewed in terms of lities of the three universal characteristics, self or I, such as “I am thinking” or “I am angry”, namely impermanence (anicca), suffering or but instead it is separated from the observer [15] dissatisfaction (dukkha) and non-self, no ego as “thinking, thinking” or “angry, angry” . or uncontrollability (anatta), can bring about Through the manner of continuously observ- re-orientation of the mind and eradication of ing and making a mental note, the thought attachment to the concept of “self” or “ego”, or anger will disappear eventually. However, which is the core of suffering[15]. during such acknowledgement, the observer must pay attention only to thoughts, feelings Psychodynamics of insight medi- or emotions such as “thinking”, “liking” or “an- tation ger”, which are ultimate realities, but not to the causes, contents or details of a mental state According to psychodynamic viewpoints, that belongs to conventional realities[23,27,28]. insight meditation (vipassana) is based on the According to Buddhist psychology, the Four Foundations of Mindfulness and can be unwholesome mental state (such as anger) categorized into six processes: cannot coexist with the wholesome mental I. Bare Attention state (such as mindfulness and wisdom) in Bare attention is clear and single-minded one moment of thought. In other words, the 212 Chiang Mai Med J 2015;54(4): mind can take only one object at a time[15]. note of or labeling it, “thinking, seeing, liking, By means of labeling or making a continuous disliking, sleepy, angry”, as mentioned before. mental note of “angry, angry”, anger or any un- These conscious mental defi lements can be wholesome mental state must disappear. This overcome by momentary removal. kind of removal is called momentary extinction (abandonment by substitution of opposites or III De-Conditioning tadanga pahana). By making a mental note Since birth, we have been conditioned of “angry, angry” at the moment of bare atten- to believe that in order to lead a happy life in tion, the anger will be substituted with mindful- this world; we must seek things endowed with ness and wisdom or clear comprehension[15,29]. (1) permanence, (2) happiness and (3) self or However, anger is abandoned for only a mo- ego. For example, if we want to buy a doll ment and it may come back in the next one. for our daughter, we must try to ensure that it Through way of acknowledgement, the medi- is durable, enjoyable, lovely and beautiful. In tator begins to observe the rise and passing of addition, most people in everyday living tend to anger and any mental state or emotion. like and dislike worldly conditions (loka-dham- In fact, bare attention is similar to wise ma) such as gain (lobha), loss (alabha), fame (yasa), dishonour (ayasa), praise (pasamsa), attention (yonisomanasikara), which is a form blame (ninda), happiness (sukkha) and suffer- of systematic thinking by way of causal rela- ing or pain (dukkha)[19,32]. tions or problem solving associated with mind- However, this kind of learning or condi- fulness and wisdom[19,29]. tioning is contrary to the teaching of the Bud- dha, who said that psychophysical phenomena II De-Repression or mind-body processes have three universal During the practice of insight meditation, characteristics, namely (1) impermanence the meditator tends to be in a state of calm and (anicca), (2) suffering or dissatisfaction (duk- relaxation, due to concentration (samadhi). kha) and (3) the non-self or no ego (anatta). Unconscious material or mental defi lements, As already mentioned, the Buddha such as thoughts, imagination, fantasies, vi- taught that “in short the fi ve aggregates of at- sions, images, feelings, emotions, anger, sexual tachment (upadanakkhandha) are the core drive, anxiety, fear, confl icts and other mental truth of suffering.” They are made up of mate- factors may arise to the conscious level. Even rial form (rupa), feeling (vedana), perception deep-seated or latent defi lements (anusaya (sanna), mental formations (sankhara) and kilesa) may fl oat up to consciousness in the consciousness (vinnana)[16, 28]. form of mid-level or obsessive defi lements All sentient beings are made up of these (pariyutthana kilesa) such as sensuous lust fi ve aggregates, which cling to their body in (kamachanda), ill-will (byapada), sloth and material form while being regarded as a per- torpor (thina-middha), restlessness, worry or manent I, my body, self, or ego. Hence the anxiety (uddhacca kukkucca), and doubt or group of material or physical forms (rupa) is uncertainty (vicikiccha)[17,19]. called the group of attachments. The mental This de-repression process is similar to state is made up of conscious and mental “free association” in psychoanalysis. The va- concomitants (cetasika) that also are grasped riety of mental defense mechanisms, particu- and taken to be the permanent mind, thoughts larly repression, is weakened in order to allow and imagination. Therefore, the mental state the emergence of repressed material. This is (nama) is known as groups of attachments. also a process of “regression in the service This is how attachment occurs as a whole in of ego” in psychoanalytical terms. However, the rupa and nama group, which is the core of mindfulness meditation is a form of mental suffering. progression or development. The meditator is advised to acknowledge the material emerg- Therefore, the de-conditioning process is ing from the unconscious by making a mental related to the technique that can eliminate this Disayavanish C, et al. Integration of psychotherapy and mindfulness development 213 group of fi ve attachments[28]. way[33]. The practice of insight meditation devel- IV New Learning ops new learning in that the fi ve aggregates People practicing insight meditation are conditioned phenomena. They arise due (vipassana) under the proper supervision of to favorable conditions and pass away with competent instructors, who act as a “guide, their cessation. With this nature of arising and mentor and good friend”, undoubtedly gain passing away, they exhibit the three universal a fundamental knowledge of the fact that all characteristics, as described previously [33,34]. compound things are made up of mind and matter (psychophysical phenomena), that all V. Working-Through phenomena relate to cause and effect, and Wisdom or insight at the experiential that they are subject to the three universal level can bring about re-orientation of the characteristics, namely impermanence (anic- mind. This kind of insight can eliminate attach- ca), dissatsfaction or suffering (dukkha) and ment or clinging to the fi ve aggregates, which non-self or no ego (anatta). can be called “ego” or “self” according to the Group of fi ve attachments at the moment psychodynamic viewpoint. However, during of seeing insight meditation the meditator may develop Attachment to visible objects (rupupadan- “resistance”, due to previously conditioned or akkhanda) arises when seeing visible objects accustomed patterns of thought, which can be impinges on the eye, thus giving rise to eye- considered as confl ict between psychologi- consciousness. The combination of visible cal progression and regression. This kind of objects, eyes, and eye-consciousness causes resistance is a major component in dynamic [30] eye contact. The visible object may be pretty, psychotherapy . At some point, experiential lovely and beautiful or unattractive, unlovable wisdom of the three universal characteristics, and ugly. Whether we feel pleasure or dis- namely impermanence, dissatisfaction and pleasure, such feelings that arise constitute non-self or uncontrollability occurs repetitively and becomes more mature and profound. attachment to feeling (vedanupadanakkhand- The progress of insight can be considered ha). When the visible object or form (rupa) has as a series of contemplation (anupassana). been seen, it is perceived and remembered The Pali term, anupassana, means “seeing in immediately, and this constitutes attachment different modes repeatedly” [35]. Visuddhimag- to perception or sannupadanakkhanda. ga[36] defi nes the three ways, as follows: The will to see a visible object is volition 1. One who repeatedly contemplates im- (cetana). Turning attention or bending the permanence of the fi ve aggregates (aniccanu- mind toward an object is manasikara. There- passana), can relinquish the wrong perception fore, cetana (volition) and manasikara (atten- that it is permanent. tion) are considered as attachment to men- 2. One who repeatedly contemplates suf- tal formations (sankharupadanakkhandha). fering of the fi ve aggregates (dukkhanupas- Knowledge of the object being seen is eye- sana), can relinquish the wrong perception consciousness because attachment to con- that it is pleasurable. sciousness or vinnanupadanakkhandha will 3. One who repeatedly contemplates self- arise[33]. lessness of the fi ve aggregates (anattanupas- In fact, at the moment of seeing, only rupa sana), can relinquish the wrong perception (body or materiality) and nama (mind or men- that it has the nature of self. tality) exist. The visible form and eye belong These kinds of repeated contemplations to rupa, but feeling, perception, mental forma- can be compared with the “working-through tions and consciousness are nama. At the process” in dynamic psychotherapy[30]. moment of hearing, smelling, tasting, touch- ing and thinking, the group of fi ve attachments VI Sharing of merits, loving-kindness (aggregates) can be understood in the same and compassion 214 Chiang Mai Med J 2015;54(4):

After practicing insight meditation, the should be focused on that spot, and a mental meditator is advised to share his or her merits, note made as “numb, numb, numb” on feeling loving kindness, and compassion to all sen- numb, as “painful, painful, painful” on feeling tient beings. Psychologically speaking, merits painful and the like. When any feeling disap- (dana), loving-kindness (metta), and compas- pears, the meditator will resume the rising and sion (karuna) are related to positive emotions falling of the abdomen and mental states. The following positive emotions are an effective antidote to negative Contemplation of the mind emotions and mental states, particularly anger, During insight meditation, it is very hard to resentment, aggression and sexual drive[15, 37]. control the mind. Though it is directed to the May all beings subjected to birth, decay, movement of rising and falling of the abdo- disease and death be happy men, the mind will not stay with them all the May they be without enmity time and tends wander to other places or think May they be without malevolence about something. This wandering or thinking May they be without physical and mental mind should not be let alone. The meditator suffering should make a mental note of “wandering, May they be happy in both body and mind wandering, wandering” or “thinking, thinking May they be able to protect themselves thinking”. On such being mindful, the mind from danger[38]. usually stop wandering or thinking, and then the practice of noting “rising, falling” should be Practice of mindfulness develop- continued. ment Contemplation of the mental objects The technique of mindfulness develop- There are various methods of contemplat- ment or insight meditation (vipassana) seven- ing the mental objects. One method is the day retreat program at Pimokmuk Institute is contemplation of twelve sense-bases. There based on the Four Foundations of Mindfulness are six external sense-bases whereby contact as taught by the Buddha, namely contempla- between the external stimuli (visible objects, tion of (1) the body, (2) the feelings, (3) the sounds, odours, tastes, tangible objects, and mind, and (4) the mental objects[15,40,41] mind objects) and the six internal sense bases (eye, ear, nose, tongue, body, and mind) can Contemplation of the body take place. The meditator gradually develops mindful- In developing insight, the meditator is ad- ness and clear comprehension by observing vised to give just bare attention to seeing, the four major postures through the practice of hearing, smelling, tasting, touching or think- sitting, standing, walking and lying down medi- ing. One can do this by making a mental note, tations. In addition, the meditator is advised to “seeing, seeing, seeing” or “hearing, hearing, practice mindfulness with clear comprehension hearing” or “tasting, tasting, tasting” in the of the minor postures, such as while eating, same manner and as the case may be. drinking, washing, dressing, bending, stretch- ing, speaking, urinating, defecating and so on. The Meditation Interview This insight meditation practice, the rising After, the insight meditation practice, the and falling of the abdomen, while in sitting meditator will have the meditation interviews meditation, is used as the main (primary or with the meditation teachers every other day, home) object of meditation. so that the progress in practice can develop continuously. Contemplation of the Feelings Because of sitting for a long time, there will arise in the body unpleasant feelings of being Demonstration cases stiff, numb, painful, hot and so forth. The mind Disayavanish C, et al. Integration of psychotherapy and mindfulness development 215

Case 1 advised to share his merits, loving kindness, The patient was a 33-year-old Chinese and compassions with himself, loved ones, man, and owner of a goldsmiths shop. He unloved ones and everyone else. needed psychiatric treatment because of his During two years of mindfulness–based wish to jump in the road and be run over by dynamic psychotherapy, as mentioned above, cars. Sometimes, he wanted to jump from the the patient’s medication was reduced gradu- third fl oor of a building. He also complained of ally and fi nally terminated. lost appetite, poor concentration, restlessness This patient still practices insight medita- and insomnia. He was diagnosed as having tion, with remarkable improvement. major depressive disorder and received treat- ment with Fluoxetine (20 mb) after breakfast, Case 2 Alprazolam (0.25 mg) 3 times a day after meals The patient was a 62-year-old woman, and Lorazepam (1 mg) at bedtime. He had been whose daughter took her for treatment, as for been married for ten years without children, many years the woman had been shoplifting and criticized his wife for being very selfi sh, from shopping centers. The stolen objects emotional and fussy. He also accused her of were not needed for personal use or monetary trying to steal gold and money from him. Fi- gain. They were taken and usually kept or hid- nally, after many quarrels they decided to stay den. Her behavior was characterized as re- in separate rooms, but in the some house. current failure to resist the impulse of stealing During dynamic psychotherapy, a therapist objects from shopping centers, which created diagnosed suicidal impulses related to anger mounting tension before the act, followed by and resentment against his wife. In addition, self gratifi cation and reduced tension, but with this anger extended to his mother, who he guilt and sometimes depression. The stealing accused of favoring his younger brother while was not planned and did not involve other being very critical of himself throughout their people. childhood. The patient was advised to prac- On one occasion, the patient was arrested tice intensive mindfulness or insight meditation for stealing a small bag in a supermarket after for seven days with the therapist, and continue CCTV camera detection. Her daughter nego- the practice at home regularly. tiated with the police and manager of the su- During his insight meditation, he could un- permarket, and promised to seek psychiatric derstand clearly the association between his treatment for her mother. Her daughter admit- suicidal impulses and the feeling of anger and ted that the patent had developed a habit for resentment toward his wife and mother. He stealing since childhood. The family history was able to deal with his anger by making a revealed that when the patient was young she continuous mental note of “angry, angry, an- was raised with two younger brothers by her gry” until it disappeared, and then resumed the mother. The patient had to take care of both main objective of meditation, i.e. infl ating and brothers, but her mother loved them more than defl ating the abdomen. Throughout this insight her. The mother ran a small shop in a market, meditation practice, the patient was able to see and that is where the patient started her his- the rise and passing away of anger and other tory of stealing money and objects. She also negative feelings or emotions by thinking, “just stole money from her relatives. watch them, accept them, acknowledge them, From psychodynamic evaluation, the pa- let them come and let them go.” At that mo- tient’s symptoms of kleptomania seemed a ment, only the mind is watching the thoughts means of restoring an unstable mother-child of anger. There is no I, self, ego, person or relationship by expressing unconscious re- individual. After anger has passed away from sentment and aggressive acts. The patient the angry mind, it is substituted with mindful- was treated with Fluoxetine (20 mg) and Al- ness and clear comprehension. prazolam (0.25 mg) after breakfast and at After insight meditation, the patient was bedtime, and dynamic psychotherapy. She also was advised to join an insight meditation 216 Chiang Mai Med J 2015;54(4):

(vipassana) retreat program for seven days to teach her about the occurrence of panic at Pimokmuk Institute (a meditation center in attacks. The patient also was advised to Chiang Mai). After three weeks meditation attend the seven-day intensive insight medi- there, she continued meditating for ten days tation program at Pimokmuk Institute. After at another meditation center. The combined three months of integrated treatment, includ- approach of treatment, which included psy- ing psychotopic medication and MBDP, the chotropic medication, insight meditation and patient’s symptoms improved signifi cantly. MBDP, showed a remarkable disappearance The relaxation response from insight medita- of her kleptomania. tion reduced her physical symptoms such as The patient was able to develop mindful- palpitations, chest pain, shortness of breath, ness or awareness as effective intervention sweating, trembling and dizziness. Techniques against the impulse to steal money or objects. from the development of mindfulness, concen- By contemplating and making a continuous tration, and wisdom could be used to overcome mental note of “knowing, knowing, knowing”, anxiety, worry, and fear, particularly regarding mindfulness (sati), concentration (samadhi), the patient’s concerns of losing control, going and wisdom (panna) developed and substitut- crazy and dying. ed the impulse to steal. After practicing insight The patient still practices insight meditation meditation, the patient was recommended to at home and is competent in applying mind- share loving-kindness (metta) with herself, fulness at work and in everyday living. She others, and particularly the people she had started to reduce the doses of psychotropic offended by stealing their belongings. medication gradually and stopped them after six months. Case 3 A 35-year-old single woman needed psy- Conclusion chiatric treatment because of her thoughts, “I According to the Buddhist doctrine, all think that I am going to die.” She stated that kinds of mental or psychiatric symptoms are during the past three months, she had been the manifestation of a form of suffering, which experiencing sudden episodes of palpitations, is in brief, related to the self or ego attach- sweating, trembling, shortness of breath, chest ment. Experiential wisdom from insight medi- pain, dizziness, numbness over the body and tation can help meditators to develop a clear fear, as if she was about to die. She went to understanding of the three universal charac- the emergency department twice and con- teristics, namely impermanence (anicca), suf- vinced the staff that she was having a heart fering or dissatisfaction (dukka) and non-self, attack. However, the results of all her physical no ego, non-entity, or uncontrollability (anatta). and laboratory examinations were within nor- In everyday living, an ordinary person tends mal limits. to be attached to oneself as “I” or “mine” or “I The fi rst episode occurred when she had am doing this, I am doing that”. One does not extra burden and responsibility in her work as only have attachment or clinging to oneself, a secretary at a university. It lasted approxi- but also to others, such as a father and moth- mately 15 minutes, and since then she expe- er, children, relatives, and loved ones. In ad- rienced similar episodes once or twice nearly dition, one also tends to be attached to money, every day. She worried about when she was property, dignity, praise and happiness. The going to have another attack. attachment to oneself, others and worldly pos- She was diagnosed as panic disorder with- sessions and situations is the cause of suffer- out agoraphobia and was treated with Fluoxe- ing. Therefore, experiential understanding of tine (20 mg) after breakfast, Alprazolam (0.25 mg) 3 times per day after meals and Lo- the three universal characteristics of mind and razepem (1 mg) at bedtime. Dynamic sup- matter or mind-body processes can lead one portive psychotherapy, particularly psychoe- to different stages of non-attachment. Hence, ducation intervention, was provided in order the improvement of psychiatric symptoms Disayavanish C, et al. Integration of psychotherapy and mindfulness development 217 among the patients in this study related clearly editors. Buddhism in psychotherapy. Kandy: Bud- to their insight or wisdom of the non-attach- dhist Publication Society; 1982. p. 17-43. ment process. 10. Epstein M. 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บูรณาการของจิตบําบัดเชิงพลศาสตร และการพัฒนาสติ

จําลอง ดิษยวณิช,1 และ พริ้มเพรา ดิษยวณิช1,2 1ภาควิชาจิตเวชศาสตร คณะแพทยศาสตร มหาวิทยาลัยเชียงใหม และ มหาวิทยาลัยมหามกุฏราชวิทยาลัย วิทยาเขตลานนา เชียงใหม, 2สาขาวิชาการบริหารการศึกษา มหาวิทยาลัยมหามกุฏราชวิทยาลัย วิทยาเขต ลานนา เชียงใหม

บูรณาการของจิตบําบัดเชิงพลศาสตร และการพัฒนาสติ หรือการใชสติเปนพื้นฐานในการทําจิตบําบัดและการ ประยุกตใชในทางคลินิกกําลังไดรับความสนใจมากขึ้นเรื่อย ๆ ในการปฏิบัติทางคลินิกมีจิตบําบัดแบบใหม หลายอยางที่ผสมผสานไปกับการเจริญสติ เชน mindfulness-based stress reduction (MBSR), accept- ance and commitment therapy (ACT), dialectical behavioral therapy (DBT) และ mindfulness- based cognitive therapy (MBCT) เปนตน อยางไรก็ตามการประยุกตใชการเจริญสติในการทําจิตบําบัด สวนใหญมักจะจํากดอยั ูแตเฉพาะประชานพฤติกรรมบําบัด (cognitive behavioral therapy) ฉะนั้นใน บทความนี้ผูนิพนธจึงไดนําเสนอแนวคิดของจิตบําบัดเชิงพลศาสตรที่อิงสติเปนพื้นฐาน (mindfulness-based dynamic psychotherapy หรือ MBDP) ซึ่งเปนบูรณาการของการเจริญสติกับจิตบําบัดดังกลาว ตามทัศนะเชิงพุทธความยึดมั่นที่มีตอตัวตน หรืออุปาทานขันธหา คือ แกนแทของความทุกขทั้งกายและใจ ระหวางการเจริญวิปสสนากรรมฐานนอกเหนือจากการเจริญสติผูปฏิบัติจะคอย ๆ พัฒนาสัมปชัญญะหรือ ปญญา ซึ่งเปนความเขาใจอยางชัดเจนวา ตัวตนที่ประกอบดวยกายกับใจนั้นยอมเปนตามกฎพระไตรลักษณ ไดแก 1) ความไมเที่ยง (อนิจจัง) 2) ความเปนทุกข (ทุกขัง) และ 3) ความไมใชตัวตน (อนัตตา) ภาวนามย ปญญาเชนนี้จะเกิดซําแล้ วซําอ้ ีกจนมีพลังแกกลาและลึกซึ้งมากขึ้น กระบวนการดังกลาวคลายคลึงกับ “การ พิจารณาซําเพ้ ื่อแกปญหา (working-through)” ในจิตบําบัดเชิงพลศาสตร ปญญาหรือความหยั่งเห็นในระดับ ประสบการณที่แทจริง สามารถลดหรือขจัดความยึดมั่นตอต ัวตนหรืออุปาทานขันธหา ซึ่งเปนแกนแทของ ความทุกขได หลังการเจริญวิปสสนากรรมฐานผูปฏิบัติจะตองอุทิศสวนบุญกุศล แผเมตตาและกรุณาใหแกสรรพสัตวทั้ง หลาย เมตตาและกรุณาเปนสภาวธรรมที่มีประสิทธิผลในการขจัดแรงขับทางเพศและทางกาวราว มีการนํา เสนอรายงานผูปวย 3 ราย เพื่อสาธิตเทคนิคของบูรณาการของจิตบําบัดเชิงพลศาสตรและการพัฒนาสติ หรือ จิตบําบัดเชิงพลศาสตรที่อิงสติเปนพื้นฐาน เชียงใหมเวชสาร 2558;54(4):209-19. คําสําคัญ: การเจริญสติ วิปสสนากรรมฐาน จิตบําบัดเชิงพลศาสตร