Mindfulness in mental illness - Kedar Nath Dwiedi
Kedar Nath Dwivedi
Mindfulness in mental illness
Mindfulness is a word from the English language, meaning awareness or heedfulness. Expressions like 'mind your language', 'mind the step', or 'mind the gap' (between the train and the platform) clearly convey this sense. However, in this paper, I also wish to refer to the Buddhist concept of it. Buddhism began in the 6th Century BC and used Pali, the popular language of the time. In Pali, there are three related concepts: Sati (mindfulness), Samadhi (absorption) and Bhavana (meditation including Sati, Samadhi and Panna or wisdom). Four aspects of Sati are described in the Satipathan Sutta, i.e. Kayanupassana satipatthan (awareness of body parts and functions such as, breathing), Vedananupassana satipatthan (awareness of sensations and feelings), Cittananupassana satipatthan (awareness of thoughts, category of consciousness etc.) and Dhammananupassana satipatthan (awareness of mental hindrances etc.) (Tin, 1989).
It is important to appreciate that this concept of mindfulness (Sati) implies a meta perspective as well, so that one is constantly aware of what the mind is doing. We may be engrossed in fantasies, thoughts, wishes, feelings, recollections, planning etc. but not realise that fact at that time (i.e. lacking in mindfulness). Achieving mindfulness is not easy and one has to put an effort and practice it as a kind of meditation (Bhavana). One of the most common methods for developing this is to practice 'anapan' or awareness of breathing. We are always breathing but seldom notice it, e.g. the touch of the breath at the nostrils. Repeated practice makes it easier.
We tend to assume that we are usually aware of our mental activities and therefore there is no need to do anything to improve or cultivate this any further. This in fact, is a mistaken belief. For example, if some one says something insulting, hurtful or nasty, it is natural for us to feel hurt or angry. This happens very fast and our breathing, heart rate, blood pressure, skin conductance etc. all change suddenly. These may change without our knowledge and certainly without our permission. We also continue to remain in such a state of mind even after the person has stopped being hurtful. The mind keeps going over and over the said phrases, the demeanour, the tone, the look, the accent and so on. The mind gets glued to these mental objects (which are just memories in this instance) which keep stirring up the feelings of hurt, anger etc. Even if someone else may be nice to us, we might not notice this because the mind is too busy with the other (hurtful) mental object.
Eventually, may be after an hour or so, we might feel not so churned up, those feelings might go out of our consciousness and become latent or dormant. However, later in the day even if we are in a pleasant situation, we might suddenly remember the incidence and once again the heart rate, breathing etc. would change dramatically. No one is insulting us then, it is purely a memory but the mind treats it as if it is real. Even the next day, the day after and so on , the same thing may happen again and again. People who have had very traumatic experiences know how distressing these flashbacks can be (Dwivedi, in press).
Similarly if we watch a horror film at night, most of us would feel scared, although there is no real creature or blood, but only glass screen, light, shade and electronics, as if the mind becomes unaware of such realities. An erotic film can in a similar way produce arousal in the viewer, although no one is doing anything in reality to him or her. Thus, our minds are very skilled in mixing the real with the unreal, as if these are water and milk.
When one feels hurt, angry, upset etc., the feelings if intense can spill over into vocal or physical actions. So, one might respond to an insult by becoming insulting oneself, verbally or physically hitting back. In this way, there seem to be three layers, i.e.
the dormant or latent stage,
mental objects in the consciousness stirring up feelings and
spilling over into actions affecting external objects.
One of the Burmese Buddhist teachers, Ledi Sayadaw (1981) who lived from 1846 to 1923 likened this to 3 levels of fire in a box of matches. Fire usually manifests whenever a match is struck. This is the second level of fire and is analogous to a mental object striking on the consciousness and stirring up feelings. The third level of fire is when the burning match comes into contact with flammable objects analogous to the emotionally charged person coming in contact with an external object and the intense feelings spilling over into vocal and/or physical action. However, the first level of fire is inherent, latent or dormant in the box of matches analogous to latent or preconscious predisposition for feelings such as, anger and so on.
This latent predisposition (Anusaya, in Pali) is a product of illusory processes creating a deep sense of self. In the presence of Anusaya, when a mental object strikes the consciousness, the feelings are stirred up because of poor mindfulness. It is because of poor mindfulness that a mental object is not appreciated as only a mental object (ideation, memory, image etc.) and is responded to as if it is a real object. The second level i. e .the stirring up of the feelings and the mind getting glued to it, is called Pariyuthana (in Pali) as if obsessed with the mental object. The third level or physical and/or vocal actions (Vitikkama, in Pali literally meaning transgression) arise if the relevant physical object comes into contact in the presence of Pariyuthana and poor volitional control.
Accordingly (Dwivedi, 1990), the Buddhist approach has been threefold: cultivating volitional control (i.e. Sila or practice of observing precepts), mindfulness (Sati and Samadhi to recognise mental objects as such and to be able to keep them at bay) and wisdom (Panna to gradually cut through the illusory processes that create this deep sense of self).
When we look at a stationary ceiling fan, we see three distinct blades, but as the fan moves fast enough the blades appear to merge into one. Similarly when we watch a cartoon film, we see creatures moving, thinking and doing things, although we know that these are simply still drawings that have been projected at a very high speed. It is this rapidity of change that creates the illusory processes. According to Buddhism, our minds operate in terms of Khanas ('mind moments'), there being 17x10 21 khanas in the blink of an eye. The sense of I, mine, me, my and that of constancy, agency, continuity, solidity in objects and relationships is the result. This is the fundamental reason behind all our suffering. Cutting through these illusory processes is not easy and can be a many lifetimes’ job.
From the Buddhist point of view, true insight or wisdom is an experiential phenomenon. It should not be confused with intellectual understanding, faith or belief. Knowledge is described to be of three kinds: Shrutmai (derived from others e.g. by reading books, listening to talks, and so on), Chintanmai (deduced through observation, experimentation and research) and Bhavanamai (experiential). For example, one can get an idea of the quality of food in a restaurant by reading the endorsements and the menu or looking at the pictures of the dishes. This is similar to knowledge (e.g. about mind-body processes) gained by reading books, watching television and listening to talks. One can deduce a better impression by looking at the delight or disgust on the faces of the customers actually eating in the restaurant. This is similar to a physicist who has investigated the nature of the universe and has firmly come to the conclusion that there is nothing solid or substantial and that everything is in a state of flux, changing, impermanent, soulless, agencyless and illusory. This is still far from being enlightened, because it is not an experiential insight. Just as one gets an idea of the true taste of the meal by eating it, an enlightened person (in the Buddhist sense) actually experiences the mind-body phenomena as illusory, unsubstantial, transient and agencyless (Dwivedi, 1994).
An essential ingredient for achieving such a wisdom is the quality of the mind. Wisdom comes when there is mindfulness and full concentration. Full concentration means a penetrative and continuous unshakeable concentration from moment to moment. In this way, mindfulness is a tool and wisdom (or enlightenment) is the goal and is seen as the perfect state of mental health in Buddhism.
Thus, Buddhism has a very clear concept of mental health promotion and how to achieve this. Mindfulness is the most important tool for this purpose. The Western mental health professionals have also begun to use mindfulness as a tool for prevention, treatment and rehabilitation as regards mental disorders. However, it is not essential that any tool for promotion can be equally beneficial for treatment. We all know that jogging can be very beneficial to health promotion but harmful if we have a broken leg. A Plaster of Paris could be helpful for such a leg but harmful as a means of health promotion for unbroken legs.
If we are suffering from a psychotic disorder, for example, it may be very difficult to follow instructions and practice mindfulness. Some clinicians have even reported deterioration in mental state in such situations. However, in most other situations, it can be rather beneficial.
Reviews of psychological mechanisms involved in meditation, psychophysiological changes, and therapeutic effects of meditation suggest various advantages (Walsh, 1979), for example, release of tension, availability of affect, openness, receptivity, sensitivity, better management of pain, performance and learning and reduction in psychosomatic symptoms, anxiety, hostility and in dependence on alcohol and drugs.
Just as the development of walking, talking and sphincter control is greatly influenced by parenting, the development of emotional management skills are similarly affected (Dwivedi, 1993, 1997a, Dwivedi & Varma, 1997a, 1997b). As there is no state of weatherlessness, there is similarly no state of emotionlessness. However, the emotions may be too subtle and preconscious and we become aware of them only when they intensify and break through into our consciousness. Even at the subtle level, they play an important role in a variety of mental functions, such as, information processing, cognition, motivation and so on. Mindfulness meditation helps to expand our consciousness and thus get in touch with such subtle emotions and thereby impact on a variety of mental functions.
Some excessively intense emotions can become traumatic and overwhelming and can trigger a chain of disastrous consequences such as, violent or destructive acting out, alcohol and drug abuse, psychosomatic illness and even psychogenic death. One may feel that such an emotional state is going to be everlasting and may not appreciate the fact that all emotions are only transient. With the help of mindfulness meditation, if one does not fight, indulge or actively avoid, they will just run their course. In fact, like taming a tiger, their energy can be harnessed for creative and constructive purposes (Dwivedi, 1996a, 1996b, and 1997b).
Human beings are symbolic mediators who can make mountains out of molehills. Through mindfulness one realises that the mind is filled with thoughts that constrict and distort our awareness as if in a state of being hypnotised by them. Through mindfulness one begins to see the thoughts for what they are, i.e. unsubstantial. It is like focussing on the empty sky, watching the clouds come and go, transient, impermanent and changing. The emphasis is on letting go, non-attachment. One begins to appreciate that the feeling of I, me, or self is just one of the numerous thought forms that flit in and out of consciousness. They seem to have a will of their own, and it is futile to control them. Most schools of psychotherapy also aim at exploring and correcting these distorted and erroneous conceptual models of reality including that of suffering, a symbolic state.
Therefore, many psychotherapists have started using mindfulness as a part of their approach (Walley, 1995). Use of mindfulness meditation in the clinical context has been reported by Deatherage (1975), Walley (1986) and Kabat-Zinn et al (1992). Epstein (1995) has shown how the Buddhist approach including mindfulness can complement, inform and energise the practice of psychotherapy. Behaviour Therapy approach for achieving relaxation also uses aspects of mindfulness practice. The Dialectical Behaviour Therapy for the treatment of severely suicidal and self harming patients diagnosed as suffering with Borderline Personality Disorder, uses mindfulness as an essential ingredient (Lineham, 1993). Jon Kabat-Zinn (1996). has developed a programme to cope with stress, pain and illness using mindfulness meditation. John Teasedale (personal communication) has found that group intervention programme incorporating aspects of mindfulness based stress reduction (as developed by Jon Kabat-Zinn) when applied to patients with recurrent depression currently in remission, is effective in halving relapse rates in patients with three or more previous episodes of depression.
In the light of the above, mindfulness meditation appears to have an enormous potential for its use as a tool by the practitioners, planners and researchers of mental health promotion.
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Dr. Kedar Nath Dwivedi, MBBS MD DPM FRCPsych,
Consultant Child, Adolescent and Family Psychiatrist,
8 Notre Dame Mews,
Northampton NN1 2BG