Clinical Handbook of Mindfulness (5 page)

illness and disease, and also from what could be termed “dis-ease,” the stress

and intrinsic unsatisfactoriness of a life that is always seeking some other

state or condition in which to feel fulfilled, complete, and happy – what the

Buddha was pointing to in his articulation of the first of the four noble truths:

in the Pali language, the actuality of
dukkha
[5].

Interestingly, the Four Noble Truths were articulated by the Buddha in a

medical framework, beginning with a specific diagnosis, dukkha itself: then

a clearly stated etiology, that the dis-ease or dukkha has a specific cause,

namely craving: a salutary prognosis, namely the possibility of a cure of the

dis-ease through what he called cessation: and fourth, a practical treatment

plan for bringing about liberation from suffering, termed
The Noble Eightfold

Path
. This is all recounted in Chapters 1 [Siegel, Germer, and Olendzky] and

Chapter 2 [Olendzky], where it is made abundantly clear that right or wise

mindfulness is one but only one of the eight path factors. However, as a

number of authors here and elsewhere point out, the term
mindfulness
(in

Pali,
sati
) has a range of different meanings that are hotly debated to this day

among Buddhist scholars, and even among scholars who share specializing

in a particular Buddhist tradition.

Perhaps it is important to state explicitly at this point that in my own

work and that of my colleagues in the Center for Mindfulness, from the very

beginning we have consciously used the term mindfulness in several com-

plementary ways: one, as an operationally defined regulation of attention

(see below); and two, as an umbrella term that subsumes all of the other

elements of the Eightfold Noble Path, and indeed, of the dharma itself, at

least in implicit form. We never limit our use of mindfulness to its most nar-

row technical sense of whether the attention is or is not fully on the chosen

object of one’s attention in any given moment. As noted, there is a consider-

able range of definitions of mindfulness even among Buddhist scholars who

specialize in the subject. I offered an
operational
definition for the sake of

clarifying what we mean when we speak of cultivating mindfulness through

both formal and informal meditative practices, namely, the awareness that

arises through paying attention on purpose in the present moment, non-

judgmentally. It was meant to be just that – an operational definition. This

approach leaves the full dimensionality and impact of mindfulness or mind-

ful awareness implicit and available for ongoing inquiry and investigation,

and indeed, it has recently become the subject of much interest and inquiry,

in the many attempts by researchers to develop with some degree of valid-

ity and precision various scales to “measure” mindfulness [see Chapters by

Brown and Cordon; and Baer, Walsh and Lykins]. Along with these attempts

come many attendant problems that are also well-recognized in these pages

and elsewhere
[6].

The choice to have the word
mindfulness
does double-duty as a com-

prehensive but tacit umbrella term that included other essential aspects of

dharma, was made as a potential skillful means to facilitate introducing what

Foreword

xxix

Nyanaponika Thera referred to as
the heart of Buddhist meditation
into the

mainstream of medicine and more broadly, health care and the wider society

in a wholly universal rather than Buddhist formulation and vocabulary. I felt

that Nyanaponika Thera’s inclusive and non-dual formulation offered both

validation and permission to trust and act on my own direct experience of

the meditation practice and the dharma teachings I had received over the

course of my life, even if technically speaking, it was glossing over impor-

tant elements of Buddhist psychology (as outlined in the Abbidharma, and

in Zen and Vajrayana teachings) that I felt could be differentiated and clari-

fied later, once it was recognized that
mindfulness
, based on our operational

definition, however, it was construed or contextualized in detail, might con-

tribute profoundly to clinical care and to our understanding of the nature

of the mind itself in a Western mainstream medical and scientific setting. In

Nyanaponka’s words, mindfulness is

the unfailing master key for
knowing
the mind and is thus the starting point;

the perfect tool for shaping the mind, and is the focal point; and the lofty

manifestation of the achieved
freedom
of the mind, and is thus the culminating

point.[7]

That means that mindfulness is the aim, the methods or practices, and the

outcome or consequences all wrapped up together, wholly fitting for a non-

dual orientation that emphasizes nowhere to go, nothing to do, and nothing

to attain [8]. Together with the words of the Buddha in his most explicit

teaching on mindfulness, found in the Mahasattipathana Sutra, or great sutra

on mindfulness

this is the direct path for the purification of beings,

for the surmounting of sorrow and lamentation,

for the disappearance of pain and grief,

for the attainment of the true way,

for the realization of liberation –

namely, the four foundations of mindfulness

it seemed like an appropriate choice to feature mindfulness as the uni-

fying factor and name under whose umbrella the work of the stress reduc-

tion clinic, later known as
mindfulness-based stress reduction
, or MBSR,

could unfold. Now we have our first clinical handbook of mindfulness, which

includes a broad range of perspectives on this veritable koan, the nature of

mindfulness, its myriad applications, and potential impacts.

To make matters even more interesting, since in all Asian languages the

word for mind and the word for heart are the same word, it feels important

to remind ourselves that unless we hear “heartfulness” when we are using

or hearing “mindfulness,” we may be missing the mark in a fundamental way

that could have unfortunate consequences both for how mindfulness-based

interventions are constructed and delivered, and for how we approach rele-

vant research issues. Many of the authors here are very strong on this point

in the discussion of their work. For me, the dimension of heartfulness re-

inforces the core Hippocratic injunction:
primum non nocere
– first, do no

harm, to which we all need to accord continual present-moment attention in

relationship to those who come to us with untold vulnerabilities.

xxx

Foreword

One last word on the subject of mindfulness and its definitions: a small

group of meditation teachers and Buddhist scholars recently developed a col-

lective articulation/definition of
mindfulness
that may contribute to the con-

versation and perhaps amplify some of these issues as explicitly addressed in

this volume. In part, it states:

.... Many contemporary Buddhist teachers use the term mindfulness in a more

comprehensive way than simply “remembering” or lacking confusion. Accord-

ing to John Dunne, Buddhist scholar at Emory University, the components of

mindfulness as it is more broadly construed might include not only
sati
, but

also
sampajanna
(meaning clear comprehension) and
appamada
, (meaning

heedfulness). Clear comprehension includes both the ability to perceive phe-

nomena unclouded by distorting mental states (such as moods and emotions)

and the meta-cognitive capacity to monitor the quality of attention. Heedful-

ness in this context can be understood as bringing to bear during meditation

what has been learned in the past about which thoughts, choices and actions

lead to happiness and which lead to suffering.

Though the contexts and interpretations of these terms may vary, scholars

and meditation teachers would probably agree on the factors of
sati
,
sampa-

janna
and
appamada
as foundational to the development of mind. Moreover,

as both Buddhist and secular mindfulness programs proliferate in the west, this

broader use of mindfulness has become a culturally meaningful and accessible

“umbrella” term for the vast majority of practitioners unversed in the intrica-

cies of translating Sanskrit or P
ali.[9]

As interest in mindfulness proliferates in both clinical and research envi-

ronments, it is critical to keep in mind and communicate to others that mind-

fulness; however, it is construed cognitively and conceptually, is a
practice
,

not merely a good idea. To my mind, one of the greatest risks we face in

this growing field is that mindfulness will be grasped and understood in a

limited way, simply as a concept. Unless we stress the element of embodied

practice and the vibrant paradox of a non-striving orientation, unless we live

it in our own lives as best we can, and allow it to inform both our research

designs and our clinical work, it may be that many people yet to come into

the field might imagine that they already understand what mindfulness is,

and insist, naively but sincerely, perhaps, that they already live in the present

moment and know how to be non-judgmental – and wonder what all the

fuss is about. What is the big deal? Without grounding our concepts, intu-

itions, and assumptions, however deep or superficial they may be, in actual

practice, the true depths of the meditation practice cannot be experienced

directly. Mindfulness as a living practice, as a way of being, makes available

to us to the full extent of our first-person experience, itself a huge mystery

worthy of scientific and philosophical inquiry and investigation
[10]
This has important implications for how mindfulness-based interventions are taught,

and for basic teacher-readiness and competency standards (see point # 8

below)
[11].

To mistake the concept of mindfulness for the actuality would be a betrayal

of what the lawfulness of dharma is offering us at this moment of confluence

between contemplative and scientific/medical disciplines. It would poten-

tially collapse the hidden dimensions that lie at the heart of authentic medi-

tative experience and eudaemonia [
12,13]
and thus deny both medicine and

psychology the possibility of investigating on a much deeper level our under-

Foreword

xxxi

standing of human nature, the nature of the mind itself, and of the mind/body

connection, with its potential practical implications for health and disease

across the lifespan. All this and more could be lost in a denaturing of the

essence of mindfulness if divorced from a non-dual perspective, wisdom,

and practice. This cautionary note must be kept in mind or our inveterate

habits of unawareness may ironically obviate this most precious and most

rare of opportunities for true creativity and healing. To that end, it is obvi-

ous that engaging in periodic mindfulness meditation retreats led by highly

developed and competent teachers is essential for all those who would bring

the practice of mindfulness into their work, whether it is on the clinical side,

the research side, or both. There is simply no substitute for using one’s own

body, mind, and life as the ultimate laboratory for investigating and refining

mindfulness. This perspective is implicit or explicitly emphasized by many

of the contributors.

The dharma as it is described in this volume, and in the huge literature on

the subject, ancient and contemporary, emphasizes that it is a living, evolving

understanding, not a fixed dogma relegated to a museum honoring a cultur-

ally constrained past. As the Dalai Lama has stated on many occasions, the

framework of the dharma welcomes being put to empirical test, and would

need to change if it is found to be inadequate in some fundamental way

according to well-accepted criteria of scientific investigation and epistemol-

ogy. Now, as the glaciers of science and contemplative practices melt into

each other (due to another kind of global warming) and move ever-faster

in tandem to carve out new understandings of the most fundamental ques-

tions of what makes us human, the nature of mind and consciousness, and

the sources of empathy, compassion, and kindness within us, this kind of

open empiricism is more important than ever. While the dharma, in its most

universal articulation, cannot and should not dictate how things should be

explored, it is important, if not critical, for clinicians and researchers to know

what they are dealing with from first-person experience before being able to

authentically test the utility, efficacy, and potential of training in mindfulness

and its sisters, loving-kindness and compassion, in the secular coordinate sys-

tem of healing and knowing within psychology, psychiatry, psychotherapy,

and medicine.

Fruitful areas for future dialogue and investigation, all eloquently addressed