Mindfulness and Mental Health

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Mindfulness and Mental Health

The secret of happiness is this: let your interests be as wide as possible, and let your reactions to the things and persons that interest you be as far as possible friendly rather than hostile.

Bertrand Russell, The Conquest of Happiness (1955: 123)

Does mindfulness inexorably support healthy development? This might be answered by a consideration of the markers of health, such as psychological status, adjustment, satisfaction and productivity, of people exhibiting different degrees of attainment. I am unaware of any study having such breadth, but counter-examples go a long way to nullify a hypothesis of this kind. While there is significant scientific and anecdotal evidence of the frequently positive impact of mindfulness on negative moods, tension and intrusive mental events, there is relatively little concerning what many would feel is a cardinal indicator of health: interpersonal relationships. We shall look first at how mental health can be thought about as something other than absence of mental illness, giving priority to models that refer to awareness and attention in developing their alternative concepts of health. These will provide a useful context in further consideration of where mindfulness stands in relation to mental health.

Mental health 

In Mindfulness – Origins and Concepts we’ve seen how, in traditional Buddhism, mindfulness was identified with a unique form of mental purification that not only overcame sorrow, distress, pain and sadness, but also set the practitioner on the right path to achieve the permanent liberation represented by Nibbana. In Science of Mindfulness we’ve also seen three contrasting types of study conducted with experienced mindfulness practitioners were reported. They were each consistent with mindfulness practice being associated with continuing changes in awareness over time, and with psychological changes taken to signify greater well-being. We’ve also discovered the different aims and methods of some Western therapeutic approaches that embrace mindfulness were outlined. These point to different ways in which it can promote health, through the prevention as well as the alleviation of recognised mental disorders. We also saw how tensions can appear between mindfulness and other aspects of a traditional psychotherapeutic framework if it is introduced. In Mindfulness Therapy For Anxiety, Depression, Anger, Trauma, Relationships, Emotional Regulation we’ve discovered the ways in which mindfulness-dependent treatments are used to relieve psychological disorders were reviewed, noting the incompleteness of the evidence at present. Analysis of its likely actions when used therapeutically for specific conditions helps to identify what may be crucial to its healing function. We’ve also discussed, the foundations or establishing of mindfulness were considered in contemporary terms. It was noted that techniques that have complemented it in traditional settings, such as practices for loving-kindness or compassion, are finding contemporary analogues too.

At least two important questions remain for this survey. One, that surfaced more than once in Mindfulness Therapy, is the extent to which it is possible to detach mindfulness as something which helps in the treatment of mental disorders from something that contributes to mental health through personal growth and the flourishing of latent capabilities.

The answers may be less obvious than they first appear. One very distinctive characteristic of mindfulness is its emphasis on process. It begins and ends with awareness, rather than any of the contents of experience. Mindfulness cannot be identified with a particular aim or a particular result. Kabat-Zinn (2005) has summarised this understanding by emphasising how meditation is a way of being, rather than a technique. While it is the nature of mindfulness for awareness to be shared without favour between all things that present to it, he also indicates the importance of being aware in a non-discursive way of factors influencing the unfolding of awareness, and of how these work either to liberate or imprison us at each moment. Because mindfulness is not about getting anything or anywhere special, but accepting how things truly are, the old lyric seems opposite: ‘It’s not what you do, but the way that you do it.’

In contrast to this focus on process, it is commonly assumed that mental health is dependent on factors such as people’s relationships or their sense of meaning and purpose. While these can support the development of mindfulness, and may benefit from it, they are not attentional processes and cannot be identified with mindfulness. An alternative construct that has been recently implicated in discussions of psychological well-being, and that is identified with attentional process, is Csikszentmihalyi’s (1990) concept of ‘flow’.

Flow and mental health

The concept of flow was refined by close attention to the experience and circumstances of people when they recognise that they are happy. Relative to overtly pleasurable situations such as eating or sex, situations in which people feel challenged yet fully engaged relative to their abilities, and carried along by the activity, are associated with even greater enjoyment. A recent summary helpfully distinguishes between features of ‘flow’ that characterize it as an experience and those that seem crucial to bringing it about and maintaining it (Nakamura and Csikszentmihalyi 2003). Five intrinsic qualities are described as follows: 1. intense, focused concentration on the here and now; 2. loss of awareness of self alongside absorption in the action; 3. confidence about being able to respond to whatever is required; 4. loss of awareness of time passing; and 5. experiencing the activity as intrinsically worthwhile. (In public lectures, Csikszentmihalyi may also emphasise the subjective serenity that accompanies the loss of awareness of self, and the sense of being outside everyday reality that amounts to ecstasy in its literal sense.) The three aspects Nakamura and Csikszentmihalyi cite as promoting flow during an activity are as follows: 1. remaining clear about immediate goals; 2. receiving continuous and clear feedback about the quality of one’s performance; and 3. having opportunities that stretch existing capacities.

There is an emphasis on process here, too, characterised by a particular quality of consciousness. Some of flow’s qualities, such as involvement, presentness and clarity, as well as its intrinsic motivation, are shared with mindfulness. Others, such as the transcendence of self and even of reality, are seemingly less so. However, the kind of absorption found in-flow is dependent upon having productive activities to be engaged in. It is also associated with achievement, the activities having to offer the right degree of challenge, as well as continual feedback. (It definitely matters what you do here, as well as how you do it.) While many people do experience such flow states regularly, there are considerable differences in the extent to which people experience it in practice. Around 15 percent of us reportedly never experience it at all. Practically, flow is an invitation to arrange life so that situations are engineered that bring the optimum level of ‘challenge’ to meet the ‘skills’ a person has. Too much challenge relative to skill brings the neutrality of ‘arousal’, leading to overt dysphoria and anxiety where insufficient skill is available. Too little challenge relative to skill, brings first the less satisfying condition of ‘control’, before relaxation sets in. Where both challenge and skill are lacking, states of apathy that are the antithesis of flow appear.

Although an alteration of consciousness is required, flow is usually brought about by indirect manipulation of factors that stimulate attention, rather than through attending to (or ‘paying’) attention directly. While its associations with happiness and productivity make flow seem a desirable state to enter, it makes an interesting phenomenon against which notions of mental health can be tested and refined. Is it the state itself or its consequences that are what would be healthy? If the state itself, can something as broad as health be identified with states that are so dependent on conditions, such as participating in activities? If the consequences are there sequelae to flow experiences that are unique to them, as opposed to a general feeling of satisfaction or happiness? And are there negative sequelae, such as indifference to other things that need attention, or an inability to divide attention, that could seem unhealthy from other perspectives?

Used in this way, the concept of flow reminds us that discussion of health quickly implicates the environment. Indeed, the difficulty of equating health with some fixed mental or bodily state, without considering the need to adapt to a given environment, has been a theme in Western medical philosophy at least since Hippocrates. Modern writers such as Rene Dubois (1966) restored this perspective in modern conceptions of health, and the possibility of identifying mental health with a balance between self and environment is being developed within the positive psychology movement by writers like Jonathan Haidt (2006).

Mental health and well-being

Recently, there has been a resurgence of interest in the concept of well-being, an appealing proxy for that of mental health when something more than the absence of illness is being referred to. ‘Well-being’ is suitably upbeat and manages to embrace being well and feeling well. These are not necessarily the same thing. A tension between being well and feeling well may go back at least to Aristotle, who developed a concept of human flourishing, or eudaemonia, that involved the realization of qualities he felt essential to the human soul. Aristotle’s own concern was that a political as well as a psychological harmony should result, with inner balance reflecting an outer one. Eudaemonia made a good candidate for a conception of mental health that reflects the importance of the environment, at the same time as accepting it could not be equated with simplistic conceptions of happiness (Nussbaum 1994).

Well-being has been adopted within the positive psychology movement to help people identify components of how they function that are already ‘signature strengths’ and others that may need attention in order to maximise personal well-being (Peterson and Seligman 2004). Accordingly, those intent on achieving well-being undergo intensive self-diagnosis, and then sign up to developing the strengths that are relatively weak through a series of exercises devised for the purpose. Haidt (2006) has commented on the confusion that can arise here between ‘relentless self-improvement’ and ‘authenticity’, as well doing may not be the same as well-being. (In other words, being well may just be being, period.)

Whatever the precise methods that are employed, an emphasis on improving well-being, over and above recovery from specific difficulties, suggests that mental health is likely to lie in the attainment of the good relations and satisfying activities and interests with which it is ordinarily associated. This involves a kind of deliberate or assisted reorganisation of one’s desires, relationships and projects, a project closer to moral regeneration than is commonly admitted. A formulation of well-being in terms of character, value orientation and relationship on the lines that have become popular among positive psychologists is congruent with the kind of enduring (if recently neglected) ideals in Western culture mentioned in earlier remarks on Aristotle. But it ignores the significance of experiential processes in a way that ‘flow’ did not. A model that managed to combine both might therefore be more helpful to the present discussion.

Cloninger’s model of health and well-being

In recent years, the internationally distinguished psychiatrist Robert Cloninger has used his understanding of psychological potential to produce an unusually comprehensive map of mental health (Cloninger 1999, 2004). It reaches from mental disorders, through a person’s capacity to adapt, toward ways of realising latent creative and spiritual capacities. In doing so, Cloninger draws on a good deal of his own work on fundamental facets of personality. Some parts appear to be more crucial to pathological development; others to self-transcendent forms of psychological growth. His work is particularly relevant in relating mindfulness to mental health because he uses degrees of self-awareness as a fundamental dimensions along which people can be separated. Some understanding of his work on personality is necessary to present this.

In his studies of personality, Cloninger identified a small number of independent components. These each correspond to behavioural and psychological traits, can be quantified, and can be demonstrated to show independent patterns of heritability and to be associated with specific patterns of brain activation. A first group, comprising four ‘temperamental’ factors, governs how people interact with stimuli in their environment from birth. These factors underpin many forms of psychopathology, especially those attributed to personality disorder. They are set out in the following box:

Harm avoidance observed as pessimistic worry in anticipation of problems, fear of uncertainty, shyness with strangers, and rapid fatiguability.

Novelty seeking observed as exploratory activity in response to novelty, impulsiveness, extravagance in approach to cues of reward, and active avoidance of frustration

Reward dependence observed as sentimentality, social sensi-tivity, attachment, and dependence on approval by others

Persistence observed as industriousness, determination, and perfectionism (linked to maintenance of reward dependence when reinforcement is very intermittent).

Cloninger’s model is particularly effective at articulating the correspondences and interrelationships between these factors. For instance, it hypothesizes that four of the personality disorders that are grouped together because of their instability in the American Psychiatric Association’s classification (APA 2004) – histrionic, antisocial, borderline, and narcissistic – each differ only in their pronounced novelty-seeking from dispositions that are, respectively, reliable, schizoid, obsessional or avoidant. A very broad spectrum of psychopathology is certainly covered.

The second set (see the following box) comprises three ‘characterological’ factors, each of which is amenable to further development as self-awareness grows.

Self-direction – being responsible, reliable, resourceful, goal-oriented, and self-confident

Cooperativeness – being empathic, tolerant, compassionate, supportive, and principled

Self-transcendence – being spiritual, unpretentious, humble, and fulfilled

Cloninger makes specific analogies between the development of these character traits and aspects of attention that contribute to the general growth of self-awareness. There is what he terms an ‘elevation’ of awareness, such that it grows in purposive impartiality and collectability. This is associated with the trait of self-directedness (and medial prefrontal activity). Secondly, there is flexibility in the breadth of attention while maintaining a mobile alertness. This is associated with cooperativeness (and networks for arousal and cooperativeness in the right frontal and inferior parietal cortex and the insula). Third, there is depth of attention, evident in a capacity to attend non-judgementally to meaningful, previously unconscious experience. (He associates this with networks for inhibitory control of conflict and self-transcendence: anterior cingulate, lateral prefrontal cortex and basal ganglia.)

In combination, permutations of the characterological factors lead to different dispositions. An ‘organised’ state results when self-direction and cooperation are present, without self-transcendence. When self-transcendence is added, a ‘creative’ disposition emerges. At the opposite pole to this creative state is ‘melancholic’ (down-cast), representing weakness in all three. This opposition between depression and creativity is borne out by Cloninger’s empirical research into the correlation of subjective happiness with the presence of these three character traits. This showed that possession of ‘self-direction’ in particular greatly influences whether a person will feel happy or sad. When self-direction, cooperativeness and self-transcendence are all lacking, the chances of feeling sad are very high indeed (Cloninger et al. 1998). Despite the differences in language and approach, there is a striking correspondence between this antithesis between creativity and melancholy, and that between ‘flow’ and ‘apathy’ found in Csikszentmihalyi’s model (cf. p. 141 above).

In placing experiential processes centre stage, Cloninger identifies three overall levels at which human awareness is organised. The first is established once there is a capacity for identifying volition, feelings and thoughts; the second, mindful, level is established once there is a capacity to be aware of subconscious material and for metacognition (albeit with retention of a sharp duality between the observer and what is observed); the third, contemplative, level is progressively non-dualistic. This means the distinction between observer and observed reduces as perception takes on a trans-personal quality and action is experienced as effortless and free from conflict. In Cloninger’s hierarchy of mental functioning, attainment of each successive level is commensurate with greater personal health.

Cloninger’s work is audacious in its breadth and combines much more detailed description of the architecture of these levels of awareness than it is appropriate to summarise here (see Cloninger 2004). He makes important proposals for practical interventions that would make these states more accessible to patients in the consulting room (cf. pp. 123-4 above). Its capacity to link the whole range of health from frank psychopathology to higher potentials deserves anyone’s further study. However, when considering mental health in relation to human potential, it was the true apostle of positive psychology, Abraham Maslow, who anticipated the usefulness of a detailed examination of the actual experiences of those people who appeared to be exceptionally healthy for a reappraisal of what it is to be mentally healthy.

Maslow and self-actualization

Maslow had a lifelong interest in human potential, which he expressed initially in his hierarchical conception of motivation (Maslow 1954). Once basic needs for nutriment, safety, association and esteem are satisfied, others, such as the search for meaning and transcendence, come into play. When he turned his attention to health, Maslow felt it should encompass the whole spectrum of activity. Equating a positive state of health with what he termed self-actualisation, he expected truly healthy people to be relatively free from frank illness; to have satisfied the four kinds of basic needs just listed; and to be demonstrably in tune with themselves through the fulfilment of the other talents and capacities they were born with. He found that people who satisfied these criteria of health were likely to have other characteristics in common, which he summarised in terms of their demonstration of a distinctive form of cognition.

Maslow distinguished between two modes of cognition. Both are based on in-depth interviews with hundreds of subjects, people who had, or had never had, the sort of self-limiting transcendental moments he called ‘peak experiences’ as well as people whom he saw as ‘self-actualising’ (Maslow 1954). Because both modes are based on detailed observation, they manage to link subjective experience with psychological generalisation. Maslow terms the first, and most usual, mode of cognition the D mode after ‘D’ for deficiency. It is commonly encountered among people who are not self-actualized and is fitted to a basic attitude to the world in which lack is ever-present. Maslow (1908-1970) was a close contemporary of Jean-Paul Sartre (1905-1980). There is an extraordinary complementarity between their work that appears not to have been recognised by commentators. Sartre’s depiction of the human condition through-out his novels and existential style of philosophising, dominated as it is by a sense of internal lack and a nihilistic attitude to a world whose fundamental characteristic is thought to be scarcity, amounts to a distillation of D cognition. Maslow’s D cognition is individualistic and instrumental. Experience is always selective, according to current motivations. Perceptions of the world are pre-categorized according to our ideas about it. Perceptions of others are filtered according to our apparent needs of them and the uses we have for them. While D cognition can supply plans and projects for managing deficiency, it has no real way of eliminating it.

The other mode of cognition was termed B cognition (for ‘being’). According to Maslow, B cognition embraces two distinct if related kinds of apprehension. In one, there is a widening of perception so that the subject is vividly aware of many levels of experience simultaneously. In the other, there is a rapt concentration on one detail that assumes total significance in itself, as many ordinarily unobserved aspects become apparent. What both sorts of apprehension share is a suspension of the sense of self, and of ordinary ideas of time and space, with a sense of unity between everything that is present.

Maslow’s ideas remain highly relevant and helpful because of the contrasts between his sketches of the D and B modes. Indeed, it would be possible to take his observations concerning D cognition to outline a psychology of mental ill-health in terms of key processes and the experiences associated with them. The various components of D functioning become exaggerated in the psychological functioning associated with the main kinds of mental disorder. For instance, the tendency to see any object as a separate part of the perceptual field extrapolates to the fragmentation of psychotic states; very selective attention is characteristic of emotional and paranoid disorders; taking repeated comparisons to extremes is common in obsessional disorders; endless calculation of usefulness characterises narcissism; and so on.

The delineation of B cognition is based on studies undertaken in the 1950s. Like William James before him, Maslow was interested in his subjects’ spontaneous experiences of transcendence, particularly those taking the form of episodic ‘peak’ experiences. These experiences can occur in many circumstances: through intense experiences of love or moments of creative productivity, or when the mind is simply in a particularly relaxed and idling state. They have a number of psychological characteristics, which Maslow has listed on different occasions (Maslow 1968, 1976). In probably his most comprehensive description, he distinguishes the following qualities (Maslow 1968: 74-96):

  1. perception of the object as a self-sufficient whole
  2. percepts exclusively and fully attended to
  3. perception freed from human motivations
  4. perceptions richer in quality
  5. perceptions impersonal
  6. perceptions self-justifying, having intrinsic value
  7. characteristic disorientation in time and space
  8. perceptions experienced only as good and desirable
  9. perceptions represent absolute, independent reality
  10. a passive and receptive quality of ‘choiceless awareness’
  11. feelings of wonder, awe, reverence and humility
  12. a sense of unity between all that is perceived
  13. ability to perceive the concrete and the abstract at the same time
  14. dichotomies, polarities and conflicts resolved or transcended
  15. experiences of love, compassion or of acceptance from a ‘godlike’ standpoint
  16. perception idiographic and classification of it resisted
  17. the loss of negative feelings of fear, anxiety, inhibition, defen-siveness, and control
  18. a dynamic parallelism between inner and outer, with the person coming closer to his or her own being.

Reports such as those cited in Science of Mindfulness suggest that it is unlikely that mindful awareness as experienced by anyone who has undergone significant training will tally with fewer than half the qualities on this list. But it is also unlikely that it will match with all of them, many corresponding instead to a level that Cloninger had seen as transcending mindfulness in referring to a higher level in terms of spontaneous contemplation. Despite the synthesizing power of Cloninger’s work and its placing ‘mindfulness’ within a spectrum of health, it is the detail of Maslow’s descriptions that provides the most accessible evidence of an association between perceptual transformations and positive mental health. Before investigating more specific associations between perception, mindfulness practice and mental health, we had better review the ways mental health is being used.

Mindfulness and the spectrum of health

When thinking about mental health as a positive achievement, rather than the treatment of mental illness, it seems three aspects can be distinguished. They will be referred to as able-mindedness, adaptation and autonomy. Able-mindedness reflects a capacity to withstand mental illness through immunity or avoiding its recurrence. As able-mindedness, mental health is identified with factors that serve to maintain freedom from illness and minimise the risk of mental disorders supervening.

Adaptation refers to the capacity to fit oneself to, and indeed thrive under, different circumstances. It underpins attempts to frame mental health positively in terms other than the avoidance of mental illness, such as the UK Mental Health Foundation’s definition (Lee 2006).

According to it, individuals with good mental health:

  • develop emotionally, creatively, intellectually and spiritually
  • initiate, develop and sustain mutually satisfying personal relationships
  • face problems, resolve them and learn from them
  • are confident and assertive
  • are aware of others and empathise with them
  • use and enjoy solitude
  • play and have fun
  • laugh, both at themselves and at the world.

(This list certainly covers positive adjustments to others, difficulties, solitude and oneself.)

The third facet of mental health, autonomy, refers to the extent of someone’s personal growth. This will involve consideration of personal adaptation, but it is essentially an expansion of the first item in the Mental Health Foundation’s definition, that is, emotional, creative, intellectual and spiritual growth, valued independently of any utilitarian or functional considerations. (Self-actualisation represents one influential way of conceptualising autonomy, if not the only one.) Autonomy includes the development of ‘higher’ aspects of mind, whether these are experiences of transpersonal feelings, creative facility, intuition of covert aspects of reality, and so forth. While it is sometimes possible to rationalise the value of such developments in terms of their being in the interests of humanity as a whole, this is likely to be misleading. Indeed, just as they may not be guaranteed to bring an individual contentment, they may sit in considerable tension with the other two aspects of mental health. This is very literally so when highly creative people, or people open to mystical experience, also exhibit the symptoms of mental illness, and their adjustment to the demands of daily living appears to be far from satisfactory from most people’s standpoint. (A useful summary of empirical work indicating that markers of positive mental health are distributed independently of symptoms of frank mental illness has been provided by Corey Keyes. However, Keyes’ (2003) own equation of positive mental health with what he terms emotional, psychological and social well-being falls entirely within the scope of ‘adaptation’ as it is used here.)

Out of these three aspects, able-mindedness may yet prove to be the most significant in relation to mindfulness. Depression is expected to become second only to heart disease on the World Health Organisation’s table of disease impacts. Preventative measures are urgently needed. However, while mindfulness may appear to be readily learned, the findings of outcome studies, as well as the literature on its side effects, suggest at present that its prophylactic value is restricted to a subpopulation of people prone to depression.

How might mindfulness enhance health with respect to adaptation and autonomy? We have already reviewed significant evidence that involvement in meditative pursuits does not necessarily guarantee health in either sense . From his clinical experience, John Suler identified the following ten negative motivations (or ‘psychodynamic issues’) for people to pursue meditation; when they are active, the student is likely to face defensive stasis, rather than greater self-awareness and transformation:

  • fear of autonomy
  • refusal to assume responsibility
  • withdrawal from relationships (as a rationalisation of fears of intimacy and closeness)
  • substitution for grief and mourning
  • avoidance of anxiety-arousing emotions (e.g. aggression)
  • passivity and dependence (as avoidance of competition)
  • self-punitive guilt (assuaged through ascetic routines)
  • competitiveness and the quest for perfection (expressed as spiritual pride)
  • devaluation of reason and intellect (with avoidance of self-reflection)
  • escape from other kinds of intrapsychic experience (e.g. denied aspects of self ).

(Suler 1993: 142-6)

Suler’s observations not only summarise points of practical importance, but also highlight the normative values of a traditional psychotherapeutic approach. From this perspective, mental health is identified with a flexible, empathic, emotionally available self that can take and assert responsibility, alongside growing capacities for feeling, intimacy, thinking and tolerance of reality. There is an unashamed model of self-development here that is apparently in conflict with meditative pursuits because these might subvert the very development the therapist is seeking. There has been a rich tradition of suspicion of this kind within the psychoanalytic tradition. It gave rise to Freud’s own conceptualization of the ‘nirvana principle’ in the service of the death instinct (Freud 1924), as well as the following trenchant judgement by him on the uselessness of Jungian therapies that appeared to him to ignore basic psycho-logical realities:

How the New ZuÈrich therapy has shaped itself under such tendencies I can convey by means of reports of a patient who was himself obliged to experience it. ‘Not the slightest effort was made to consider the past or the transferences. Whenever I thought that the latter were touched, they were explained as a mere symbol of the libido. The moral instructions were very beautiful and I followed them faithfully, but I did not advance one step. This was more distressing to me than to the physician, but how could I help it? – Instead of freeing me analytically, each session made new and tremendous demands on me, on the fulfilment of which the overcoming of the neurosis was supposed to depend. Some of these demands were: inner concentration by means of introversion, religious meditation, living together with my wife in loving devotion, etc. It was almost beyond my power since it really amounted to a radical transformation of the whole spiritual man. I left the analysis as a poor sinner with the strongest feelings of contrition and the very best resolutions, but at the same time with the deepest discouragement. All that this physician-recommended any pastor would have advised, but where was I to get the strength?’ (Freud 1914a: 63-4)

The most incisive analytic critique of how and why meditative training may fail to help people overcome basic and long-standing difficulties with adaptation is that it underestimates our natural gift for self-deception, because there is insufficient understanding of unconscious mental processes. This is the view of Barry Magid, a psychoanalyst and Zen teacher, whose opinions reflect many years spent providing clinical services to experienced meditators (Magid 2002). Magid’s experience also underlines how decisive the contribution of the meditation teacher can be in determining whether meditation serves either to perpetuate long-standing psychological difficulties, or to support independent psychotherapeutic efforts to resolve th

There are, of course, considerable paradoxes in claims about the non-therapeutic potential of meditation. In Mindfulness Therapy For Anxiety, Depression, Anger, Trauma, Relationships, Emotional Regulation we’ve reported some expectations that mindfulness practice would be clinically useful in the very areas of intimate relationships and self-functioning that are apparently being denied or bypassed here. It might be claimed that these criticisms are more likely to apply to the limitations of more concentrative forms of meditative practice. Mindfulness could be relatively immune if performed properly, it would always facilitate experiencing inner events (however unpleasant) closely, objectively and acceptingly, as an alternative to defensive avoidance.

Engler on the fruits of mindfulness

Such claims and counterclaims can only be decided by experience. Someone well placed to do so is Jack Engler, who has many years’ personal experience as a psychotherapist and a teacher of insight meditation. Engler had been a principal investigator in the study of perception among Western and Eastern mindfulness meditators summarised in Science of Mindfulness. The apparently much slower progress and lower achievement of the Western meditators this revealed indicated to him that the Westerners’ internal emotional and psychological difficulties interfered with their capacity to be mindful. He felt Eastern subjects, relatively lacking in such conflicts, progressed much further, more rapidly. Engler found support for these inferences by reverting to traditional clinical methods for interpreting the subjects’ responses to the Rorschach projective test in his secondary analysis of the study’s findings (Brown and Engler 1986).

As a psychotherapist, Engler had taken care to ensure that the engagement of affect as well as cognition was not ignored when explaining the traditional Buddhist understanding of the conditioning of perception to Western students. Together with his own experiences of the co-occurrence of psychological and meditational difficulties in patients and students, Engler came to an important, developmental formulation of the relative contributions of psycho-therapy and meditation to health:

Problems in love and work, and issues around trust and intimacy in relationships in particular, can’t be resolved simply by watching the moment-to-moment flow of thoughts, feelings, and sensations in the mind. Thirty years of watching students try this approach bear that out.

(Engler 2003: 45)

Twenty years earlier, Engler had distinguished three distinct types of psychopathology (Engler 1986). These represent a developmental sequence, and can be characterised in terms of different types of ego functioning. He observed that there is no real equivalence between the first two of these and anything in Buddhist psychology, because of the latter’s lack of interest in psychological development. However, both of them will be familiar to most Western psychotherapists. The first type of organisation, attributed to early failures in the differentiation between self and others and in the establishment of a cohesive sense of self, is associated clinically with the features of borderline psychopathology. Loss of continuity in the sense of self, extreme affects, highly distorted experiences of others (which may be linked to extreme and inappropriate reactions to them), and even hallucinatory phenomena are typical.

The second type of organisation is one in which a relatively differentiated and integrated sense of self is present, alongside actively warded-off feelings and impulses. This is associated clinically with neurotic psychopathology in which high levels of anxiety are experienced. The patient’s range of feeling, perception and action is restricted as part of an adaptation to the relatively stable exclusion of some contents from consciousness. Only in the third type of organisation is the self well-differentiated and integrated and free to function relatively effectively.

Engler sees distinct implications for meditation and therapy with regard to the first of these states. Essentially, mindfulness practice has no part to play in its alleviation, because the uncovering action of mindfulness is likely to amplify the diffusion of identity that pre-exists in this kind of personality organization. The attendant risk is that the very fragile, residual self-structure present would be over-whelmed by the contradictory and intense affects and impulses that would be uncovered. Engler points out that this is particularly important to recognise, because people suffering from such states of mind are quite likely to turn to meditation in an effort to find the calm and detachment they lack. He notes that, if they begin intensive mindfulness practice, their increasing disorientation and distress will take expression in extreme reactions to the meditation teacher – a situation with which teachers are all too familiar. Engler feels that, if meditation has a role here, it is likely to be in the form of concentrative practices that help to focus attention elsewhere and can lead to positive feelings of well-being.

He says very little about the second state, despite the fact that much of the material already reviewed in Mindfulness Therapy For Anxiety, Depression, Anger, Trauma, Relationships, Emotional Regulation illustrates how the judicious use of mindfulness might, through reassimilation of fended-off contents, lead to the kind of internal mental reorganisation that would restore a well-differentiated and integrated self. However, the omission may be significant in the light of his own (and Suler’s) observations on the relative impotence of meditation in resolving difficulties in the areas of trust, intimacy and, by implication, conflicts concerning sexual wishes. While these can have underlying psychological patterns that resemble those found in, say, some conflicts surrounding the expression of aggression and assertion, I have yet to meet an experienced clinician who felt the most intimate relational problems could be resolved in the absence of a close working relationship with a therapist (or therapeutic group) or without experience of actual relationships outside therapy. However, the question of whether there may be any intrinsic therapeutic limits to mindfulness here is complicated by the context of intensive mindfulness practice that Engler is referring to – that is, a quasi-religious setting. Different attitudes concerning intimacy and sexuality may be being explicitly or implicitly conveyed there that complicate attempts to confront this kind of difficulty through mindful uncovering, in a way that may not apply to other kinds of personal difficulty.

In passing over this whole topic of mindfulness’ possible role with problems arising from his second kind of self, Engler continues to side rather fatalistically with the outlook of traditional teachers. He links Western students’ poor progress to their pre-occupations with internal contents. A quotation he offers elsewhere from a visiting Asian teacher seems apposite: ‘Many Western students do not meditate. They do therapy. They do not go deep with mindfulness’ (Engler 1986: 29).

In fact, it seems Engler’s principal purpose in delineating the three developmentally distinct states is to highlight the peculiarities of the third and most developed state. And these are absolutely central to the concerns of this article. In the West, the third state, in which the self is simultaneously well-differentiated, integrated and apparently stable, is regarded as normal; in fact, healthy. According to Engler, it represents a distinct form of pathology, albeit a kind of pathology that is not recognized in the West. The issue is one of ‘conditioned states’, in which the very achievement of a stable sense of self and of the relations it has with objects beyond it constitutes a problem. Rephrased in psychotherapeutic language, this self remains a form of arrested development through unnecessary fixation. Engler sees mindfulness meditation as the therapy within Buddhism whose objective is to alleviate the suffer-ing that follows from living with a self of this kind. The effects of mindfulness that were explained in Mindfulness – Origins and Concepts in terms of the categories of Buddhist psychology can, in psychotherapeutic terms, be said to ‘set ego and object relations development in motion again from a point of relative arrest’ (Engler 1986: 48). Engler is making a direct comparison here with the uncovering action of psychoanalysis, while conceding that, in so far as the two practices achieve this internal freeing, they do so by very different means. According to him, mindfulness works by watching the reversal of the representational processes that give rise to the sense of ‘self’ and ‘object’ so that these are deconstructed into their elementary components, with a fundamental reversal of the way the world appears.

In his more recent comments, Engler (2003) admits limitations to his developmental perspective. The idea that an unconditioned state might be deliberately attained from conditioned ones is particularly problematic, as it is inherently contradictory (cf. Krishna-murti’s comments on this point, p. 124 above). Because of its utter difference from apparently static selves, Engler joins Coltart and others in suggesting that the deconstructed self that is liberated (and which corresponds to the concepts of ‘no self’; ‘not I’; ‘no mind’; ‘big mind’, and so on, favoured by other writers) does not have to replace the ordinarily healthy one. What matters is that an utterly free process is no longer impeded. As this becomes paramount, the criteria for health and suffering can also shift. Engler describes how, with increasing experience of mindfulness, ordinary operations of registering pleasure or constancy become sources of pain in this state of awareness. Any approach/avoidance response to pleasure and pain, no matter how ‘normal’ in everyday experience – the simplest responses of attraction and aversion, wanting and not wanting, preferring pleasure and avoiding pain, wanting this and not wanting that – irrespective of their particular aims and objects – is experienced as an extra-ordinarily painful and misguided effort to block the natural flow of events. Any attempt to constellate a separate and continuous representation of self, or to preferentially identify with some self-representations as ‘me’ and extrude others as ‘not-me’ is experienced as an equally futile and painful attempt to interrupt, undo, or alter self-representations as a flow of moment-to-moment constructions. (Engler 2003: 69-70)

By now, there is little question of the no-self state being healthy because of some function it has. It is preferred because it is a fuller expression of our nature, a state that can be identified with being itself. There is a sense here in which such contentions cannot be a matter of argument. Only experience can convince. However, as Stephen Mitchell demonstrates in a response to Engler’s paper, it is possible to retain scepticism of such claims, while remaining sympathetic to a positive, transpersonal conception of health (Mitchell 2003).

Being, being mindful and being healthy

Our earlier discussion of well-being had taken us to the beguiling threshold of Maslow’s being world. The transformations in his self-actualized subjects’ sense of themselves and of the rest of reality, and their abilities to interact easily and even inspire those around them, were related to a perceptual change expressed as their openness to peak experiences. Maslow describes these peak experiences as introducing a fusion of experience and value, so that self-actualized people have a very clear sense of what is intrinsically good in the moral sense. ‘Peak experiences’ have an astonishing fluidity and vitality that fit well with Engler’s observations on the perception of everything being in motion. However, they do not seem to carry the painful sensitivity Engler reports in relation to any perceived obstruction to an ideal state of absolute flow.

Can anything meaningful be made of this contrast? One thing both sets of reported experience are touching on are ideals and values. It seems likely that heightened perception challenges ordinary conceptions of the fact/value divide. This is not to say that Maslow’s account, for instance, is accurate in all circumstances. The premonitions it appears to offer of a world of absolute values informing events appears to be a very comforting one. It coheres beautifully with his own hierarchical analysis of human motivation and needs. Indeed, it has been an extraordinary twentieth-century reworking of Plato’s ontology in contemporary terms. However, some awkward questions persist. How far had Maslow’s psychology been shaped in response to his own needs, rather than being a necessary interpretation of the observations available to him? In a review of this work, his own student, Richard Lowry, comments that Maslow’s work on peak experiences and self-actualization never gained the professional acceptance that his work on the hierarchy of motivation had. Lowry outlines how Maslow came to acknowledge for himself that his selection of candidates for his self-actualisation studies reflected a wish to understand the lives of people that he personally idealised (Lowry 1999). This, rather than extraneous psychological considerations, seemed to determine the template according to which his candidates were measured. The admirable characteristics of the self-actualized person were themselves an ‘ideal type’ (in the Weberian sense) that no single individual ever matched in their entirety. What is more, the idea that Maslow proceeded from an idea of health to discover that what healthy people have in common is B values was illusory? As Lowry notes, Maslow admits in his own journal that he was, in fact, selecting people for study because they used ‘B language’ and excluding others if they did not, even if they still met the health criteria for inclusion. What was presented as being resulted from bias.

Nevertheless, Maslow’s increasing preoccupation with value as something that is embedded may reflect an empirical truth of a different kind. It can seem that the uncovering attention of mind-fulness works to reveal values that lend experience a form of coherence that is not ordinarily apparent. It is not uncommon for this to find expression as meditators believe they are discovering some kind of transmissible truth or wisdom about reality as their explorations proceed. This may be further encouraged if an expectation that it will result in ‘insight’ is widely accepted, although teachers in the mindfulness/vipassana tradition tend to emphasise the immediate, intuitive and non-conceptual nature of realisations concerning the ultimate nature of things and to be dismissive of students’ verbal formulations. In Engler’s description of perceptual insight, there was a striking vision of how things should be, the sensations of pain he reports cohering with this.

A sense of intrinsic value is evident there too. But is it finally a necessary one, reflecting an absolute quality of being? Or is it a contingent one that would be resolved through further refinement of the meditator’s perception? This question goes to the heart of the traditional conception of mindfulness and its role in personal transformation that was outlined in Mindfulness – Origins and Concepts. There we saw how the final section of the greater sutta on the foundations of mind-fulness dealt with mindfulness of the mind’s contents in terms of teaching or dhamma. These teachings comprise statements about the basic divisions of reality (physical and psychological) that, as their labels’ language of ‘hindrances’ or ‘enlightenment factors’ suggests, are inseparable from values. Yet, the sutta is curiously ambiguous concerning the approach the meditator might adopt in relation to these elements. The account provided in Mindfulness – Origins and Concepts reflects prevalent teaching that a kind of submission to the eternal truth of this dhamma is required . Perception is to be aligned with it, all experience being appreciated as conforming with its categories. (The responses of the Eastern master to Engler and Brown’s projective testing in Science of Mindfulness seems an excellent example of this.) This would affirm a transcendent sense of order that supports many noble and subtle values, including those concerning health, that called the satisfactoriness of the ordinary self so sharply into question.

However, another reading of the treatment of mental objects in the sutta is possible. It is the simplest, in that mental objects, even dhamma teachings, are treated no differently from anything else that presents to awareness. The task is to penetrate deeply into their arising and passing away too. They are no more welcome to take root than any other object or mental content, however great the temptation. As a repository for values central to the whole system of Buddhist thought, mind objects such as the Four Noble Truths would be the most tenacious, still conditioning a monk’s perception once all else has been allowed to fall away. On this alternative reading of the sutta, they become the final obstacle rather than the final truth. Once they, too, can be experienced like any other object, mindfulness has been truly established. Only then does a process without any restriction or conditioning remain.

Words are likely to be of very limited help in portraying such a state. By extrapolating from mindfulness’ apparently distinguishable psychological actions of dechaining, resensing and decentering, something of the experience of things once aware-ness is freer might be inferred. All three actions would now be unfettered, bringing about a reversal of perception. Each component, however small, would have a quality of completeness in itself. They would also be vividly alive, interpenetrating and containing their opposite. And, instead of an observer reaching out to the world with awareness, there would only be an impersonal awareness in which everything was held. There is a logic to this, and a resonance with several (if not all) of Maslow’s observations on peak experience and B perception. If such a shift in perception also brings with it a fundamentally different relationship to reality, which is precisely what talking about ‘being’ here implies, then former judgements about what is healthy and what is not lose their relevance. What represents either adjustment or autonomy in relation to the ground of our being may have little in common with what counts as adjustment or autonomy in the context of the familiar, conditioned world. Indeed, it is hard to imagine, if terms such as adjustment and autonomy retain any meaning in this different context, how they would not be the same thing.

If mindfulness actually led its practitioners completely out of themselves, bringing them directly into a non-dual universe permeated by B values, there would arguably be little more to say on the question of health. Old standards need not apply. However, despite traditional teaching’s implication that mindfulness provides sufficient means, this is not necessarily the case. Cloninger, for instance, had not linked mindfulness to a world of this kind (which corresponds to his contemplative level) but to one that is transitional between ordinary modes of awareness and others associated with even greater inner freedom. The retention of an attenuated sense of oneself, attuned to different aspects of sensory experience but in which one still relates to it as an observer, was confirmed by the group interview with experienced mindfulness teachers reported in Science of Mindfulness.

John Welwood is another clinician who has not been afraid to consider the ontological implications of his far-ranging experiences in psychotherapeutic work. His ‘transpersonal’ outlook is indebted to Buddhist schools that came after the Theravadan traditions from which the basic theory of mindfulness has been drawn. However, Welwood (2000) recognizes a very similar spectrum for the organisation of awareness to Cloninger. Mindfulness comes about midway along Welwood’s sequence also. What is singular to his approach is the description of a distinctive cognitive process for each stage. In sequence, these are as follows:

  • Conceptual reflection. A sense of separation and flexibility is achieved through articulation of experience.
  • Phenomenological reflection. There is an openness to direct and preconceptual experience, untrammelled by language.
  • Reflective witnessing. Here, ‘bare, mindful attention’ attends to the flow of experience rather than to individual objects within it.
  • Transmutation. A qualitative shift permits immediate aware-ness of life and intelligence within coarser perceptions.
  • Continuing self-liberation. With the disappearance of a sense of an observing self, one of unitary presence supervenes.

Its midway position in schemes like Welwood’s and Cloninger’s indicates that mindfulness is a transformative process, assisting access to more refined modes of being conscious. However, its role in the kinds of personal development being considered here appears to be a transitional, rather than an ultimately liberating, one. This status seems congruent with mindfulness’ ambiguous contemporary image as a health-promoting as well as a spiritual practice. In fostering qualities of equanimity and tranquillity alongside an unusually acute and open awareness, it is likely to be adaptive in many contexts where resilience and performance are favoured. Mindfulness resembles Csikszentmihalyi’s ‘flow’ in this, if differing a little in the quality of awareness that results (and differing from flow a lot in the limitlessness of the situations to which, by definition, it can be opened). This developmentally transitional quality of mindfulness indicates a potential to promote a form of personal growth that, like other versions of autonomy, cannot be reduced entirely to either able-mindedness or adaptation, although it subsumes them. At the same time, this potential is not identical to kindred developments such as ‘self-actualization’. To understand just what its contribution to personal autonomy may be, and the ways in which it may remain limited, we are likely to have to fall back on two pillars of this book, Buddhist theory and science.

Buddhist theory is quite clear that truly stable equilibrium is attained only once a fundamental quality of no-self (anatta) is realised, dissolving distinctions between individual beings. Psycho-logically, too, this seems an unequivocal basis on which distinctions between able-mindedness, adaptation and autonomy not only recede, but vanish altogether. However, we have seen in Mindfulness – Origins and Concepts some ways in which there is a possibly necessary ambiguity in Buddhism concerning the extent to which mindfulness, as one component of a system whose interrelations can seem infinitely intricate, represents sufficient means for realising such a state. (Examples were the need for the action of mindfulness to be complemented by ‘clear comprehension’ (cf. p. 19 above) or practices in which exercises to develop mindfulness are supplemented by others that foster appreciation of more subtle, transpersonal feelings (cf. p. 20). Others could be cited.)

As for science, the evidence from qualitative and physiological studies of mindfulness meditators in Science of Mindfulness appears to mirror this ambiguity. Considered against findings from people accessing states where anatta is more evident, these support the notion that, irrespective of their transformational potential, mindful states of consciousness occupy the middle ground within a broader spectrum. Moreover, observations made in Science of Mindfulness concerning the coincidence of mindful practices and psychiatric symptoms (as well as work cited in the previous section of this article) indicate how, despite occasionally wilful attempts to show other-wise, science does not recognise neat lines between psychological states taken as indicative of positive mental health and other experiences usually attributed to mental illness.

Part of the genius of Buddhism has been to link aspects of spiritual attainment with psychological changes that can be expressed in cognitive terms. This has made it appealing to people in the West who are respectful of reason, and who believe in human potential, but distrust deist religions. However, it appears that the more ultimate goals heave into view, the clearer the gulf between Buddhism’s values and those of Western psychology becomes – however ‘positive’ the latter may take itself to be. It would seem that, so far as mindfulness is concerned, thinking of health in terms of positive states or qualities of being is not necessarily helpful. Despite doing so, we have still not identified what is most distinctive to mindfulness’ contribution.

Health, self-knowledge and suffering

There seem to be several ways to go at this point. One is to get increasingly preoccupied with goals (and there are few more compelling than health) and their interrelationship with mindfulness and the practices that foster it. The project that Shapiro et al. (2006) have initiated into the colouring of practice by values, alongside other apparently determinant factors, is an important response to this kind of dilemma. We saw in Science of Mindfulness how these inter-relationships, which cast doubt on the apparent unity of mindfulness, deserve and are amenable to further empirical exploration.

Another response is to question the value of explorations of the goal of health in the kind of terms adopted above, in favour of recollection of some aspects of the West’s indigenous transformative psychologies. As we noted in Mindfulness Therapy, interest in mindfulness is being accompanied by a wider resurgence in the popularity of Buddhistic ideas. Among the consequences of this are a growing acceptance in the West of generalised references to Buddhist teachings, such as the self being illusory or everyone being responsible for their own salvation. Alongside this, and despite its actual consequences for others, the more uncomfortable particulars of self-delusion can go unexamined. Whether or not such blindness misrepresents Buddhism, it represents a failure to appreciate or recollect lessons available through Western depth psychologies. A loss of working familiarity with the understandings that have informed psychoanalysis and analytic psychology – for instance, how it is no more possible to escape our psychological shadow (comprising all that we disown) than our physical one – means people are more likely to be blind to themselves. It also suggests they will be condemned to rediscover them in some other way.

One frequent and widely shared aspect of self-delusion is an almost insatiable need to idealise – whether through fantasies about attaining states of radiant enlightenment, or in dreams of treatments that will magic away every trouble and worry. The phenomenon of mindfulness, like the chimera of health, is open to idealisation in both of these ways. Paradoxically, being driven by ideals (rather than resting in moment-to-moment awareness) seems like a recipe for disabling mindfulness, because more and more ground for dissent opens up. This is not inevitable. Mindfulness teachers such as Jon Kabat-Zinn do recognise that ‘We need to develop and refine our mind and its capacities for seeing and knowing, for recognizing and transcending whatever motives and concepts and habits of unawareness may have generated or compounded the difficulties we find ourselves embroiled within’ (Kabat-Zinn 2005: 62). But what is the nature of that need?

A third response to the impasse over health is to seek an alternative basis for understanding and practice that still bridges Buddhist and Western outlooks. A prime candidate would be the apparent antithesis of health: suffering. Perhaps suffering is where this exploration needs to finish. In Mindfulness – Origins and Concepts, we saw that the most fundamental assumption within Buddhist ontology is that reality has three inescapable characteristics – those of suffering (dukkha), impermanence (anicca) and no-self (anatta). The pursuit of health has led us progressively toward the uplands of anatta and away from the other bases, including suffering. This pursuit has also threatened to go beyond mindfulness, as well as providing more and more reminders of the residual differences, if not incompatibilities, between Buddhist and Western approaches. If, instead, we ask what common concern motivates the two traditions – Buddhism as a practical discipline, and the Western tradition of practical philosophy that modern psychotherapy has descended from (Mace 1999a) – we return to suffering. Working with mindfulness enhances sensitivity to the presence and the nature of suffering. The importance of responding to suffering is the essential common ground between Buddhist and Western practices, as mindfulness becomes an aid to health.

In Buddhist theory, the roots of suffering lie in desire, aversion and delusion. It could be argued that recognition of the clinical importance of each of these, to the relative exclusion of the others, has inspired the psychoanalytic, behavioural and cognitive movements, respectively, within modern psychotherapy. From the Buddhist perspective, desire, aversion and delusion are interdependent, with the implication that therapeutic approaches that embody mindfulness fully would have the capacity to work with all three. At present, we have noted that existing mindfulness-based therapies appear to differ in their actions. These differences can be analysed in terms of the combination of dechaining, resensing and decentering that seems characteristic of a given approach. Analysis of these constituent actions was founded in experience as well as inference, being supported by introspection as well as external observation of clinical effects and hypothesis testing. However provisional this three-action model may prove, there are also striking complementaries between dechaining and desire; resensing and aversion; and decentering and delusion, where one is an antidote to the other. While mindfulness-based treatment approaches have developed in significant ways, their evident differences and limitations suggest that, like more traditional psychotherapies, they may not have realised their full potential to influence mental suffering. If they are to do so, their prospects seem likely to depend upon fuller appreciation of the interconnections between insights from therapy, theory and science.


Mental health can be understood as freedom from mental disorder (able-mindedness), as optimal adaptation, or as fulfilment of potential (autonomy). Developments in physiology as well as psychology have made it possible to sketch a model of well-being that interconnects all three conceptions of positive mental health and links them to different forms of awareness. The phenomenon of ‘flow’ provides a good instance of how a healthy state can be identified with its attentional characteristics, although its range is limited. When mindfulness is considered in relation to positive mental health, different aspects of its action come to the fore than in discussions of its strictly therapeutic use. Its role in preventing emotional disorder is likely to be important in relation to able-mindedness. Its potential contribution to adaptation is less clear at present, with limits apparent in how far it could contribute to healing relationships, for instance.

Consideration of health as self-development highlights the difference between an individualistic psychology and one where the ordinary self is, by definition, less than healthy. Mindfulness may offer an accessible way of loosening (but not eliminating) this self-structure, although pre-existing psychological difficulties are likely to complicate the process. Developments of this kind are probably less dependent on being healthy and on being well adapted than Maslow’s being psychology had suggested. Identifying health with more traditional spiritual ideals opens up many incompatibilities

References and Further Reading

  1. Russell, B. (1955) The Conquest of Happiness. London: Allen & Unwin.
  2. Kabat-Zinn, J. (2005) Coming to Our Senses. New York: Hyperion.
  3. Csikszentmihalyi, M. (1990) Flow: The Psychology of Optimal Experience. New York: Harper & Row.
  4. Nakamura, J. and Csikszentmihalyi, M. (2003) The construction of meaning through vital engagement. In Flourishing (eds C. Keyes and J. Haidt), Washington, DC: American Psychological Association, pp. 83-104.
  5. Dubois, R. (1966) Man and His Environment: Biomedical Knowledge and Social Action. Washington, DC: World Health Organization.
  6. Haidt, J. (2006) The Happiness Hypothesis. London: Heinemann.
  7. Nussbaum, M. (1994) The Therapy of Desire: Theory and Practice in Hellenistic Ethics. Princeton, NJ: Princeton University Press.
  8. Peterson, C. and Seligman, M. (2004) Character Strengths and Virtues: A 174 References Handbook and Classification. Washington, DC: APA/Oxford University Press.
  9. Cloninger, C. (2004) Feeling Good: The Science of Well-Being. New York: Oxford University Press. 
  10. Cloninger, C. R. (1999) A new conceptual paradigm from genetics and 168 References psychobiology for the science of mental health. Australian and New Zealand Journal of Psychiatry, 33, 174-86.
  11. Cloninger, C. R., Bayon, C. and Svrakic, D. M. (1998) Measurement of temperament and character in mood disorders: a model of fundamental states as personality types. Journal of Affective Disorders, 51, 21-32.
  12. Maslow, A. (1954) Personality and Motivation. New York: Harper.
  13. Maslow, A. (1968) Towards a Psychology of Being (2nd edn). New York: Van Nostrand Reinhold. References 173. 
  14. Maslow, A.  (1976) Further notes on cognition. In The Farther Reaches of Human Nature, Harmondsworth: Penguin, pp. 249-55.
  15. Lee, M. (2006) Promoting Mental Health and Wellbeing in Later Life. London: Mental Health Foundation and Age Concern.
  16. Keyes, C. (2003) Complete mental health: an agenda for the 21st century. In Flourishing: Positive Psychology and the Life Well-Lived (eds C. Keyes and J. Haidt), Washington, DC: American Psychological Association, pp. 293-312.
  17. Suler, J. (1993) Contemporary Psychoanalysis and Eastern Thought. Albany, NY: State University of New York Press.
  18. Freud, S. (1924) The economic problem of masochism. In Standard Edition, vol. 19, London: Hogarth, pp. 159-72.
  19. Freud, S. (1914a) The History of the Psychoanalytic Movement. In Standard Edition, vol. 14, London, Hogarth, pp. 7-66. 
  20. Magid, B. (2002) Ordinary Mind. Boston, MA: Wisdom.
  21. Brown, D. and Engler, J. (1986) The stages of mindfulness meditation: a validation study. In Transformations of Consciousness (Also in Journal of Transpersonal Psychology (1980), 12, 143-92) (eds K. Wilber, J. Engler and D. Brown). Boston, MA: Shambhala, pp. 161-91.
  22. Engler, J. (2003) Being somebody and being nobody. In Psychoanalysis and Buddhism (ed. J. Safran), Boston, MA: Wisdom Publications, pp. 35-100.
  23. Engler, J. (1986) Therapeutic aims in psychotherapy and meditation: developmental stages in the representation of the self. In Transformations of Consciousness (originally in Journal of Transpersonal Psychology (1984), 16, 25-61) (eds K. Wilber, J. Engler and D. Brown), Boston, MA: Shambhala, pp. 17-51. 
  24. Mitchell, S. (2003) Somebodies and nobodies. In Psychoanalysis and Buddhism (ed. J. Safran), Boston, MA: Wisdom, pp. 80-6.
  25. Lowry, R. (1999) Preface. In Toward a Psychology of Being (ed. R. Lowry), New York: Van Nostrand, pp. 1-20.
  26. Welwood, J. (2000) Reflection and presence: the dialectic of self-knowledge. In Toward a Psychology of Awakening, Boston: Shambhala, pp. 98-129 (also in Journal of Transpersonal Psychology (1997), 28, 107-28).
  27. Mace, C. (ed.) (1999a) Heart and Soul: The Therapeutic Face of Philosophy. London: Routledge.


Chris Mace

Chris Mace is the author of Mindfulness and Mental Health: Therapy, Theory and Science.