Dialectics of Mindfulness: Implications for Western Medicine
Philosophy, Ethics, and Humanities in Medicine
May 2011
Abstract
Mindfulness as a clinical and nonclinical intervention for a variety of symptoms has recently received a substantial amount of interest. Although the application of mindfulness appears straightforward and its effectiveness is well supported, the concept may easily be misunderstood. This misunderstanding may severely limit the benefit of mindfulness-based interventions. It is therefore necessary to understand that the characteristics of mindfulness are based on a set of seemingly paradoxical structures. This article discusses the underlying paradox by disentangling it into five dialectical positions - activity vs. passivity, wanting vs. non-wanting, changing vs. non-changing, non-judging vs. non-reacting, and active acceptance vs. passive acceptance, respectively. Finally, the practical implications for the medical professional as well as potential caveats are discussed.
Background
In the last two to three decades, the concept of mindfulness has received increasing attention, particularly in the health sciences. Mindfulness is about being aware of actual experiences from one moment to the next with gentle acceptance [1-3]. This concept has been proposed to contribute to the coping and recovery process in many health conditions.
Both clinical as well as basic science researchers have devoted a significant amount of study to this topic [4]. Moreover, with rapidly mounting evidence regarding the therapeutic capacities of mindfulness practice, medical professionals are increasingly incorporating such techniques into their clinical repertoire. Probably the best known and evaluated mindfulness-based treatment is the Mindfulness-Based Stress Reduction (MBSR) that is used in many clinical settings in the US and Canada and evermore, in Europe [4].
Yet, integrating mindfulness into existing therapeutic concepts may challenge medical professionals' usual practices for number of reasons. First and foremost, mindfulness approaches do not aim at symptom reduction.
Fundamentally, mindfulness is not intended to explicitly eradicate pain, distress, or unwanted emotions. However, philosophically and practically, medical professionals endeavor to reduce suffering. If mindfulness does not aim at reducing symptoms, then how can it be helpful? In this essay, we argue that while mindfulness is not meant to actively reduce symptoms, it may passively modify their impact by changing an individual's perceptions and mindset. Mindfulness is a set of practices, if not a "way of being" that may incur salutogenic (i.e., health-promoting) effects. This may lead to a misconception of what mindfulness is, and how it works. We believe that some of the apparently contradictory aspects of mindfulness can be best understood by taking a dialectical approach. It is not a new idea to explain psychological health-related processes through the use of paradoxical or dialectical approaches [5]. Indeed, we propose that the dialectical structure of mindfulness hallmarks its essence, which may easily be misunderstood in clinical practice.
The dialectical approach is quite different from the conventional approach of symptom evaluation. The conventional approach uses the current logic: a symptom is either good or bad; present or absent; relevant or not. The dialectical approach stresses that each thesis also has to be considered in the light of its opposite (the antithesis), and only both facets together (the synthesis) yield a full picture. In this light, depression might be a sign of a disorder that should be mitigated. But at the same time, it must be acknowledged that there are inner experiences that cannot be controlled or altered "at will". Hence, although the phenomenal quality of going through depression may not be altered, a patient's relation towards relevant inner states relevant to depression may be changed due to mindfulness or other forms of spiritual exercise [6,7].
Herein, we first elaborate on the dialectical structure of mindfulness by providing an overview of 1) the theoretical foundation of the construct, 2) evidence of the clinical effectiveness, and 3) putative neurobiological correlates of mindfulness. We then introduce five dialectical positions that we believe are useful for resolving the apparent paradox associated with mindfulness and its relevant mechanisms of action. Finally, on the basis of this discussion, we derive the utility and implications of mindfulness for medicine, and address potential caveats...
Conclusion
A number of practical conclusions may be drawn from the five forms of dialectics of mindfulness: (1) activity vs. passivity, (2) wanting vs. non-wanting, (3) changing vs. non-changing, (4) non-judging vs. non-reacting, and (5) active acceptance vs. passive acceptance, as presented in this paper. To begin with, individuals in a state of distress have a natural longing for suffering to end. Therefore, despite the well supported clinical efficiency of mindfulness treatments, it is crucial to explain to a patient that mindfulness is not a remedy such as anesthesia or analgesia. This is not to say that mindfulness is not intended to help - of course it is. But as it will help an individual "only" to live with the reality of a present moment, it should correspondingly be understood as a change in one's point of view, rather than a direct attempt to diminish a symptom. This is particularly relevant to the western medical system, given that modern medicine with all its successes and advantages has also fostered chronicity of certain illnesses that cannot be cured, and so must be cared for. Mindfulness may be a suitable avenue to that end.
Mindfulness is an approach that can be used to change reaction(s) toward unwanted experiences. Patients need to be aware of this point in order to avoid unrealistic expectations that may lead to disappointment before consenting to a mindfulness based intervention. To be more precise, a medical professional should be very clear when communicating to patients about what may not change (the symptom), and what may change (the relationship towards the symptom). As mindfulness practice may easily be misunderstood, "side effects" such as disappointment may occur as a result of having misinterpreted the concept.
Second, both theory and data corroborate that mindfulness is an experientially oriented approach. To become familiar with this different way of thinking, and in this way mobilize possible health benefits of mindfulness, it is necessary that patients practice regularly and actively. Accordingly, mindfulness interventions should not focus on theoretical discussions or explanations, but rather support active practice, although an initial orientation and repeated explanations may be necessary. In some ways, mindfulness is like swimming - it is best learned by doing. To date, conceptualizing along the lines of a dose-effect model, there are no valid conclusions regarding how much training is needed. However, most existing mindfulness interventions (such as the MBSR) work with rather high treatment schedule (e.g., 30 minutes homework per day and two hours group session per week) [34].
Third, the acceptance aspect of mindfulness should not be taken to the extreme. As stated above, it would be contrary to the concept of mindfulness (and also counterproductive) to simply embrace anything that happens with an accepting attitude. Rather, individuals exercising mindfulness on a regular basis should learn to voluntarily suspend the judging process as best possible. It is crucial to bear in mind the distinction between active and passive acceptance, as discussed above. It should also be stressed that mindfulness is not meant to be a "stand-alone" treatment. To the contrary, mindfulness approaches should be combined with more change-oriented approaches. Not doing so would entail the risk of providing suboptimal clinical intervention.
Patients should be encouraged to observe and register inner experiences without reacting to them. For this reason, some mindfulness schools teach student(s) to verbally express sensations. For example, in a case where the mindfulness student experiences a sensation of pain in the foot, the student would just state this perception- "there is a certain feeling of pain in the middle of my right foot"- without reacting to it.
The main caveat of working with mindfulness techniques is not to succumb to the escapist conception that one could "meditate the problem away by mindfulness". This would not be consistent with the nature of mindfulness. The problem is that clinicians (and perhaps humans, in general) are trained to think in cause-effect relations, try to identify the root of a problem, and then try to eliminate the cause. Without a cause, the problem should go away, and correspondingly the problem would seem to have vanished. This approach, although perfectly useful for survival in the external world, and despite having yielded tremendous progress in natural science and technology, may not work in the cognitive-emotional realm. Mindfulness training challenges the thought "if I get rid of my anxiety, I will live a fulfilled life" and replaces it with the statement "If I learn to accept my anxiety, I will eventually learn to live with it". This reflects the insight that although one cannot live a life without experiencing fear, she may be able to learn to master it. In other words, mindfulness may be a means by which one may be able to live a fulfilled life with a disorder by (passively) accepting it. Mindfulness should not be considered as a tool of cause-effect thinking. This is a difficult point, and it should be acknowledged that mindfulness involves a way of looking at the realities of the world that is different for much of a predominant paradigm of modern medicine.
In sum, mindfulness may prove to be an effective complementary approach that can be employed in a number of conditions to lessen subjective "illness". However, as we've shown, mindfulness differs substantially from the way that Western medicine approaches malady. Therefore, any medical professional who plans to incorporate mindfulness approaches into her therapeutic repertoire needs to recognize that it involves a dialectical, and not an "engineering"/curing, process. The dialectical character of mindfulness discussed in this essay is by no means complete; there are other aspects that may be worthwhile. Nevertheless, we believe that the five dialectical positions discussed - activity, wanting, change, judging, and acceptance - offer a promising starting point for understanding the construct(s) and process of mindfulness and its mechanisms of action.
In time, empirical evidence may elucidate in what circumstances, and to what extent mindfulness might be most useful within the therapeutic palette of clinical medicine. Our ongoing work is committed to this effort.
Full Text (open access)
Philosophy, Ethics, and Humanities in Medicine
May 2011
Abstract
Mindfulness as a clinical and nonclinical intervention for a variety of symptoms has recently received a substantial amount of interest. Although the application of mindfulness appears straightforward and its effectiveness is well supported, the concept may easily be misunderstood. This misunderstanding may severely limit the benefit of mindfulness-based interventions. It is therefore necessary to understand that the characteristics of mindfulness are based on a set of seemingly paradoxical structures. This article discusses the underlying paradox by disentangling it into five dialectical positions - activity vs. passivity, wanting vs. non-wanting, changing vs. non-changing, non-judging vs. non-reacting, and active acceptance vs. passive acceptance, respectively. Finally, the practical implications for the medical professional as well as potential caveats are discussed.
Background
In the last two to three decades, the concept of mindfulness has received increasing attention, particularly in the health sciences. Mindfulness is about being aware of actual experiences from one moment to the next with gentle acceptance [1-3]. This concept has been proposed to contribute to the coping and recovery process in many health conditions.
Both clinical as well as basic science researchers have devoted a significant amount of study to this topic [4]. Moreover, with rapidly mounting evidence regarding the therapeutic capacities of mindfulness practice, medical professionals are increasingly incorporating such techniques into their clinical repertoire. Probably the best known and evaluated mindfulness-based treatment is the Mindfulness-Based Stress Reduction (MBSR) that is used in many clinical settings in the US and Canada and evermore, in Europe [4].
Yet, integrating mindfulness into existing therapeutic concepts may challenge medical professionals' usual practices for number of reasons. First and foremost, mindfulness approaches do not aim at symptom reduction.
Fundamentally, mindfulness is not intended to explicitly eradicate pain, distress, or unwanted emotions. However, philosophically and practically, medical professionals endeavor to reduce suffering. If mindfulness does not aim at reducing symptoms, then how can it be helpful? In this essay, we argue that while mindfulness is not meant to actively reduce symptoms, it may passively modify their impact by changing an individual's perceptions and mindset. Mindfulness is a set of practices, if not a "way of being" that may incur salutogenic (i.e., health-promoting) effects. This may lead to a misconception of what mindfulness is, and how it works. We believe that some of the apparently contradictory aspects of mindfulness can be best understood by taking a dialectical approach. It is not a new idea to explain psychological health-related processes through the use of paradoxical or dialectical approaches [5]. Indeed, we propose that the dialectical structure of mindfulness hallmarks its essence, which may easily be misunderstood in clinical practice.
The dialectical approach is quite different from the conventional approach of symptom evaluation. The conventional approach uses the current logic: a symptom is either good or bad; present or absent; relevant or not. The dialectical approach stresses that each thesis also has to be considered in the light of its opposite (the antithesis), and only both facets together (the synthesis) yield a full picture. In this light, depression might be a sign of a disorder that should be mitigated. But at the same time, it must be acknowledged that there are inner experiences that cannot be controlled or altered "at will". Hence, although the phenomenal quality of going through depression may not be altered, a patient's relation towards relevant inner states relevant to depression may be changed due to mindfulness or other forms of spiritual exercise [6,7].
Herein, we first elaborate on the dialectical structure of mindfulness by providing an overview of 1) the theoretical foundation of the construct, 2) evidence of the clinical effectiveness, and 3) putative neurobiological correlates of mindfulness. We then introduce five dialectical positions that we believe are useful for resolving the apparent paradox associated with mindfulness and its relevant mechanisms of action. Finally, on the basis of this discussion, we derive the utility and implications of mindfulness for medicine, and address potential caveats...
Conclusion
A number of practical conclusions may be drawn from the five forms of dialectics of mindfulness: (1) activity vs. passivity, (2) wanting vs. non-wanting, (3) changing vs. non-changing, (4) non-judging vs. non-reacting, and (5) active acceptance vs. passive acceptance, as presented in this paper. To begin with, individuals in a state of distress have a natural longing for suffering to end. Therefore, despite the well supported clinical efficiency of mindfulness treatments, it is crucial to explain to a patient that mindfulness is not a remedy such as anesthesia or analgesia. This is not to say that mindfulness is not intended to help - of course it is. But as it will help an individual "only" to live with the reality of a present moment, it should correspondingly be understood as a change in one's point of view, rather than a direct attempt to diminish a symptom. This is particularly relevant to the western medical system, given that modern medicine with all its successes and advantages has also fostered chronicity of certain illnesses that cannot be cured, and so must be cared for. Mindfulness may be a suitable avenue to that end.
Mindfulness is an approach that can be used to change reaction(s) toward unwanted experiences. Patients need to be aware of this point in order to avoid unrealistic expectations that may lead to disappointment before consenting to a mindfulness based intervention. To be more precise, a medical professional should be very clear when communicating to patients about what may not change (the symptom), and what may change (the relationship towards the symptom). As mindfulness practice may easily be misunderstood, "side effects" such as disappointment may occur as a result of having misinterpreted the concept.
Second, both theory and data corroborate that mindfulness is an experientially oriented approach. To become familiar with this different way of thinking, and in this way mobilize possible health benefits of mindfulness, it is necessary that patients practice regularly and actively. Accordingly, mindfulness interventions should not focus on theoretical discussions or explanations, but rather support active practice, although an initial orientation and repeated explanations may be necessary. In some ways, mindfulness is like swimming - it is best learned by doing. To date, conceptualizing along the lines of a dose-effect model, there are no valid conclusions regarding how much training is needed. However, most existing mindfulness interventions (such as the MBSR) work with rather high treatment schedule (e.g., 30 minutes homework per day and two hours group session per week) [34].
Third, the acceptance aspect of mindfulness should not be taken to the extreme. As stated above, it would be contrary to the concept of mindfulness (and also counterproductive) to simply embrace anything that happens with an accepting attitude. Rather, individuals exercising mindfulness on a regular basis should learn to voluntarily suspend the judging process as best possible. It is crucial to bear in mind the distinction between active and passive acceptance, as discussed above. It should also be stressed that mindfulness is not meant to be a "stand-alone" treatment. To the contrary, mindfulness approaches should be combined with more change-oriented approaches. Not doing so would entail the risk of providing suboptimal clinical intervention.
Patients should be encouraged to observe and register inner experiences without reacting to them. For this reason, some mindfulness schools teach student(s) to verbally express sensations. For example, in a case where the mindfulness student experiences a sensation of pain in the foot, the student would just state this perception- "there is a certain feeling of pain in the middle of my right foot"- without reacting to it.
The main caveat of working with mindfulness techniques is not to succumb to the escapist conception that one could "meditate the problem away by mindfulness". This would not be consistent with the nature of mindfulness. The problem is that clinicians (and perhaps humans, in general) are trained to think in cause-effect relations, try to identify the root of a problem, and then try to eliminate the cause. Without a cause, the problem should go away, and correspondingly the problem would seem to have vanished. This approach, although perfectly useful for survival in the external world, and despite having yielded tremendous progress in natural science and technology, may not work in the cognitive-emotional realm. Mindfulness training challenges the thought "if I get rid of my anxiety, I will live a fulfilled life" and replaces it with the statement "If I learn to accept my anxiety, I will eventually learn to live with it". This reflects the insight that although one cannot live a life without experiencing fear, she may be able to learn to master it. In other words, mindfulness may be a means by which one may be able to live a fulfilled life with a disorder by (passively) accepting it. Mindfulness should not be considered as a tool of cause-effect thinking. This is a difficult point, and it should be acknowledged that mindfulness involves a way of looking at the realities of the world that is different for much of a predominant paradigm of modern medicine.
In sum, mindfulness may prove to be an effective complementary approach that can be employed in a number of conditions to lessen subjective "illness". However, as we've shown, mindfulness differs substantially from the way that Western medicine approaches malady. Therefore, any medical professional who plans to incorporate mindfulness approaches into her therapeutic repertoire needs to recognize that it involves a dialectical, and not an "engineering"/curing, process. The dialectical character of mindfulness discussed in this essay is by no means complete; there are other aspects that may be worthwhile. Nevertheless, we believe that the five dialectical positions discussed - activity, wanting, change, judging, and acceptance - offer a promising starting point for understanding the construct(s) and process of mindfulness and its mechanisms of action.
In time, empirical evidence may elucidate in what circumstances, and to what extent mindfulness might be most useful within the therapeutic palette of clinical medicine. Our ongoing work is committed to this effort.
Full Text (open access)
