Monday, January 27, 2020

Integrating Buddhist Practices and Modern Psychotherapy


Recent decades have witnessed a remarkable trend in psychology, practical philosophy and the self-help sector. Buddhist  practices emphasizing "radical acceptance" (such as mindfulness based on Vipassana and Zen traditions) have become prominent aspects of both the academic and popular spheres of discourse in clinical psychology.  Additionally, Greco-Roman Stoicism (which also emphasizes calm detachment from desires) has also influenced psychologists and self-help authors in recent decades. In terms of the practical or applied aspect of this trend, there are many relatively new therapeutic modalities that emphasize the acceptance of environmental conditions and internal mental states in a non-judgmental manner. For example, Dialectical Behavioral Therapy, Acceptance and Commitment Therapy, Mindfulness Based Cognitive Therapy and several others all tout the virtue of achieving a state of detachment from one's own desires, thoughts, sensations and emotions while cultivating awareness of the phenomena from moment to moment. This depends on the ability to calmly experience both pleasant,unpleasant and neutral states in the ongoing present without attempting to alter them or avoid them. This is achieved in some cases through formal meditation combined with psychotherapy, and in other cases informally  (i.e. without  meditation practices).  Hospitals, clinics, training centers for therapists and text-books have increasingly taught and implemented therapeutic modalities of this kind for everything from  PTSD, depression and anxiety, to chronic pain, addictions, stress reduction and anger management. But the underlying psychology comes both from ancient Stoicism and some forms of Buddhism, both reinterpreted for a late-modern and more or less secular therapeutic consumer culture. What is "radical acceptance" such that it can be seen in both, for example Zen Buddhism and new approaches to Behavioral Therapy? How does it fit into a culture based largely on the ideas of progressivism and meliorism (the idea that by controlling, influencing or changing the world we find increased well-being both socially and psychologically)? How do Buddhist philosophies that aim to help us evaluate and reduce our cravings and desires find a place in modern Western culture which is so inextricably bound up with consumerism (which is based largely on appealing to our fleeting and impulsive desires?)

Radical Acceptance, on one psychologist's definition, means "completely and totally accepting something from the depths of your soul, with your heart and your mind. You stop fighting reality." (Karyn Hall: 3 Blocks to Radical Acceptance, Psychology Today,12/5/13) Typical examples, some of which Hall discusses,  include accepting the reality of bumper-to-bumper traffic when you are already late to an important meeting; accepting the reality that your spouse has cheated on you; accepting that life isn't fair and you may suffer injustices such as being passed over for a job that is given to someone unqualified instead of you. The idea is that the more you "fight" these realities, the more you end up nursing grudges and resentments that lead to anger, anxiety and depression. Why? Because (and this is the Stoical/Buddhistic premise) these realities are simply out of our hands. We cannot control or even significantly influence such external events in the world. Our best bet is to be at peace with them even though we may not like or approve of the behaviors and actions that bring them about. So accepting is not the same as liking or approving of unpleasant realities. Rather, it amounts to achieving an attitude of calm understanding that although often we can't control the events themselves, we can strive to modify our responses to the events so that at least they do not cause us undue suffering.

Buddhists and Stoics have long held that we have extremely limited control over external conditions, but that we can come to skillfully exercise influence over our interior world of emotions, thoughts, desires, and expectations. Indeed, it is true that in Ancient Rome or India external hindrances to well-being were very largely beyond the control of human agency. But in the wake of the scientific, industrial and political "revolutions" of the past few centuries, the balance of human influence over the environment and other people has changed considerably.

In ancient India and Rome even the most high-born ranks of society were at the mercy of the elements in ways we are not, and those who were not aristocrats were socially impotent in the face of injustice. Today the combination of technological innovations and political rights and freedoms for many people has made it possible to change external realities that had previously been called unchangeable. We live in the midst of constant attempts to reconfigure norms and  behaviors we don't "accept" because they are seen as being unfair. Suffragettes; civil rights activists; same-sex marriage; advocacy for altering carbon emissions in recognition of the profound influence we do have over external conditions (and with this influence a corollary responsibility to ourselves and future generations); the fight to extend available medical interventions to all citizens precisely because they do influence the course of illnesses and induce health-- all these and other examples make plain that Western history veered away from stoical acceptance which Hegel described as a form of "Unhappy Consciousness." In a concealed reference to Marcus Aurelius, the Roman emperor and philosopher, and to Epictetus, a Roman slave who became a philosopher, Hegel, in Phenomenology of Spirit, writes "whether on the throne or in chains . . . [the Stoic's] aim is to be free, and to maintain that lifeless indifference which steadfastly withdraws from the bustle of existence" (§199, 121). The historical context for such a withdrawal from external relations is, he continues,  "a time of universal fear and servitude..." (ibid). That is, stoicism emerged in the context of a society in which there was widespread fear of contradicting or deviating from the governing norms and institutions (the Roman Empire).  Modernity in the West, though, embraces a philosophy of ameliorating social and environmental ills through interactive, rational interventions in science, technology, applied ethics (e.g. the Human Rights Movement) and political reform and/or revolution (both the American and French  serving as archetypes for the modern age).  So when Dr. Hall (quoted above) and others say that it is utterly "futile" to suffer frustration in traffic, or to  be angry about  having been treated unfairly, we need to examine this claim more carefully.

First, as Hall and others readily acknowledge, in keeping with Stoical and Buddhistic philosophies, most of the time we cannot directly control the reality of feeling anger, frustration, disappointment and so on. To exercise stoical self-control we must  incorporate psychological principles and cultivate practices that allow us to feel that anger or disappointment without acting on it. We learn to sit with it patiently, enduring the displeasure without judging it to be "bad" or "good" or anything else. Acceptance depends on detachment from ones' feelings and passions just as with the ancient philosophies. However, this detached acceptance of emotional and mental states, if and when it is embodied "radically," may be at odds with deep convictions Westerners often have about the function of emotions in everyday life.

Let's say that after a few years of practicing deep acceptance,  one is no longer so readily disturbed by the misfortunes of bumper-to-bumper traffic,  being cheated on, or being passed over for a job that someone less qualified ends up getting. Of course, acceptance does not mean the person now likes or approves of these conditions-- but since the troubling situations can't be changed, they are not resisted (one "stops fighting reality" as Hall says in above quote). But there is a big difference between saying that I can't change the traffic I'm already in today and I can't attempt to solve the frustrating problem of highway congestion in general so that others and I will not have to keep "accepting" the problem. This is where meliorism (progressively improving external and internal conditions in terms of our shared values and goals) can come into conflict with radical acceptance. According to meliorists like the American Pragmatists or civil rights pioneer WEB Du Bois, we must first  believe in our ability to change all kinds of daunting external and internal situations in order to influence them. That is, the "can-do" philosophers of progress  challenge us to imagine bold solutions that may seem unrealistic based on current conditions and standards. Crucially, such a "will to believe" depends on treating unpleasant emotional states not in a detached but passionate manner.

For example, in Rome, Epictetus (the Stoic) was a slave who claimed that he was free internally because he accepted his condition. I suppose modern slaves (both those in US history and those now subject to human trafficking) could adopt some such acceptance of the "unchangeability" of these massive social institutions and networks. After all, any one individual living under such draconian conditions might have only a slim chance of ever achieving liberty. But if this virtual inevitability fails to stir up anger, resentment, anxiety, depression, fear and all the other disturbing states that trauma usually leaves in its wake, then the motivation to protest and agitate for change may not come about. It seems that activism is itself a byproduct not of detachment from but passionate engagement with our unpleasant emotions and their external causes.  The meliorist does not "accept non-judgmentally" but rather passionately condemns and resists situations taken to be caused by external  forces even if those forces are unlikely to simply disappear. What is all-important is the belief that, in principle, the offensive conditions and resulting "negative emotions" can be changed by human intervention. It is this possibility which provides hope and motivates action.While therapies and philosophies based largely on radical acceptance tend to focus on the internal conditions of the subject, in many real-life scenarios the problem/s may well be external and objective.  In such instances,  "negative" emotions (e.g. anger, fear, sadness et al.) can be interpreted as perfectly natural signs indicating just what is problematic "out there" in the external world.  The emotions may well function both as information about and motivation to fight unwanted conditions in our lives.  If we seek to attenuate such emotions, loosening their grip on us, we may lose an important spur to action as in the case of anger leading to  activism or sorrow serving as an inspiration to compose a poem or music, or even as a source of psychological insight. Mindfulness and acceptance of emotions is a valuable skill, but it is not always the best or most appropriate way of understanding and  dealing with difficult emotions.

Indeed we live in a geological age some earth scientists call the "anthropocene" because it is held that we have influenced the earth dramatically in ways dangerous to ourselves and myriad species in the biosphere. If there is an answer to global climate change, it is clear that we will have to first truly feel rightly pissed off about the apathy of politicians and corporate elites that would leave the earth in a dangerous state to their own children. This is part of the message the activist Greta Thunberg imparts wherever she goes.Without righteous anger, without passionate condemnation, there will be no course-correction. What do the advocates of radical acceptance say about this line of thought?

Here, the best response can be summarized by quoting from Reinhold Niehbuhr's "Serenity Prayer." Putting aside the belief in God, it expresses a principle such that one seeks too acquire:

"The serenity to *accept* the things I cannot change, the courage to change the things I can, and the wisdom to know the difference."


This seems to be a reasonable way to combine stoical acceptance with proactive meliorism so as to have the best of both worlds. Something along these lines is just what is often endorsed by advocates of acceptance-based therapies and recovery programs. They often speak of "balancing acceptance and change."  It is held that in order to change things we must first accept them. But the problem is that it begs our original question which is "Just what things can we change, and which things can't we change?" Saying that I will try to accept those things I can't change makes sense only if I really can't change them. What is needed is "the wisdom to know the difference" between what can't  be changed and can, and such determinations are almost always controversial. One person may hold that socio-political conditions can't be changed and fall into apathy while the activist refuses to give up. So we're back to square one trying to evaluate what turns out to be an attitudinal bias either in favor of the will to believe that we CAN influence many events against all odds or believing that we cannot. In other words, much of the evaluation of what can and can't be changed is not deducible on logical grounds alone but involves basic temperament, viz. optimism and pessimism. One person's "realistic optimism" may seem overly cautious and pessimistic to a another person more predisposed to fiery activism. The standards of what can and can't be changed  are often based not on knowledge and evidence,  on any unequivocal but rather such elements as confidence, tenacity, inventiveness and hope. It may have once seemed "unrealistically optimistic" to suppose humans can fly or that governments can be changed so that they address such things as the rights of not-very-powerful minorities. Indeed, there are hard limits to what can be achieved in such areas.  But who among us can claim to know exactly where these limits lie, or what can and cannot be altered in advance? So, if someone experiences intense righteous anger in the present moment because they are addressed with a racial epithet, as has been the case many times before, they might say to themselves: "This already happened. I can't change it. I can't change the past. I am hurting now and must accept the situation. Only if I fully accept it can I later think about changing it." But it may be that equally valid is thinking about the  external cause (systemic racism) while feeling rightly angry and indignant so that there is sufficient motivation to join others in fighting the problem that led to this painful experience and myriad others just like it. Those who cultivate a serene acceptance may suffer less emotional distress as a result in the long run ( a therapeutic advantage); but they may also have diminished motivation to passionately resist the status quo.

Certainly monastic Buddhism and Roman Stoicism have often failed to challenge the status quo. Traditional Buddhist monks leave the everyday world, forego family life, and carry a begging bowl for all necessary funds. The monastic centers have usually depended on the patronage of those with wealth and power. Roman Stoics seldom discussed social and political reform, if at all. From the Emperor Marcus Aurelius to the slave Epictetus, one's lot in life is to be accepted. I mention these facts because these ancient philosophies are the basis of much of the modern work on acceptance. The principle expressed in the Serenity Prayer does not provide details regarding what we can and cannot change. But Buddhist dharma and the teachings of Greco-Roman Stoics that have inspired the new therapies do provide clear guidance on that point. Here, for example,  is Epictetus' principle of differentiating that which we can and cannot change:


“Some things are in our control, while others are not. We control our opinions, choice, desire, aversion, and, in a word, everything of our own doing. We don’t control […] everything not of our own doing.”  (Enchiridion/Handbook of Epictetus)

Or Gautama from the Dhammapada:

"Let a man put away anger, let him renounce pride. Let him get beyond all worldly attachments; no sufferings befall him him who is not attached to name-and-form [nama-rupa or phenomenal existence] and who calls nothing his own.

He who curbs his rising anger like a chariot gone astray (over the plain), him I call a real charioteeer; others but hold the reins (and do not deserve to be called charioteers)." (Sections 221-222 Dhammapada) 



Compared to moderns, these ancient quotes reveal great confidence in the earnest disciple's  ability to control internal processes including what we think, feel, desire, avoid and choose. Modern western culture operates on very different assumptions. We are socialized to believe that strong desires (tanha  or craving in Buddhist terms) and emotions, for example, arise involuntarily, and that at best we can try to tweak those thoughts, beliefs and desires which make us suffer but cannot completely overcome them. An obvious case in point is the nearly universally held belief in "romantic love." We moderns can't help "falling in love." We enjoy and suffer from the passions and longings that "move" us emotionally in life. Romance is just one example of an obvious and intense kind. Who today believes that our "opinions" (as Epictetus says)  about foods, music, movies, friends, acquaintances, jobs, social statuses and roles (to name a few) are really within our "control" as individual agents? Ancient Stoicism and Buddhism both  teach that with proper training, we can control much of this. The quote from the Dhammapada above asks all disciples to "get beyond all attachments," which certainly includes romantic longings along with strong desires for material wealth, status, sex, pleasant foods we come to crave,  et. al.  I don't think this is compatible with the much more deterministic ideas we have such that we have innate (perhaps genetic or otherwise "hard wired") preferences, dispositions, temperaments and traits of character.

On the other hand Epictetus and Gautama are adamant about our helplessness regarding  that which we, according to them, cannot control. Again, quoting Epictetus and the Buddha:

"We do not control those things not of our own doing" (Epictetus: ibid)those things not of our own doing"

"Not the unworthy actions of others, not their misdeeds of commission and omission, but one's own misdeeds of commission and omission should one regard."(Dhammapada: S. 50)

 Both quotes express the conviction that what we can and should change are our own thoughts, desires and actions, not those of others.  But in our outer-directed culture, it is the desire to change others, to convince them to think and do as we would have them think and do, that is prized above the rigorous training of our own minds.  This, by the way, is not necessarily a bad thing in every case. For it includes the value placed on individuals having a meaningful role in trying to change or shape socio-political  events and forces as well as interpersonal behavior directed at each of us by others.
Within our modern culture--steeped in individuality, utilitarianism, and the "can do" philosophy of meliorism-- most of us surely think we can influence, and at times control external doings and happenings. To this end we try to learn "how to influence others" to "get our way" -- which interestingly is a part of Dialectical Behavior Therapy skills training, viz. "Interpersonal Effectiveness." The dialectical relation between acceptance and change in DBT puts the scale far closer to modern conceptions of agency than do the Stoics and Buddhists that influenced Marsha Linehan, the founder of DBT. I can't go into depth here, but in the tradition (Zen) she studied, it is held that there is no "self" to even change. These are deep philosophical issues, and I only point at them in passing to indicate how ambiguous the notion of "balancing acceptance and change" really is once we try to apply the distinction situationally in everyday life.  Judgments regarding what we can and can't control have a lot to do with socio-cultural, technological  and historical context, which-- unfortunately-- most psychotherapy fails to address (with exceptions such as Erich Fromm and Karen Horney).

I think that we moderns tend to believe that "willpower"and instrumental action are effective until we find ourselves unable to "get out of a rut"-- whether in a difficult relationship, addictions, unemployment, suffering abuse, feeling lingering anxiety or depression etc. In the parlance of 12 step psychology, we tend to assume we're in charge of things until we "bottom out," whether as a result of alcohol, drugs or counterproductive attachments ("addiction") to food, sex, gambling or whatever else it may be.  If instrumental approaches to changing these internal and external states of affairs fail, some of us may lose confidence in our own efficacy and become receptive to acceptance-based approaches to living like the 12 step program, or the new therapies influenced by Buddhism and Stoicism. There are certainly limits to what we can change, but again it's not clear how these limits vary not only from person to person but cultural context to cultural context. The philosophy of meliorism asks us to stand strong despite defeat, and to affirm a kind of heroic conception of life as the overcoming of obstacles. This is a big part of our culture ("you can do anything you put your mind to"  or "you can make it if you try") which countervails acceptance-based life orientations and therapeutic"strategies.


For example, WEB Du Bois, influenced by William James and other meliorists, claimed that only if we first believe in our capacity to redeem the world can it come to pass. Sometimes there is no epistemological basis for accepting or rejecting a belief (especially beliefs about future states of affairs). When we are acting in a context of unknowns, beliefs may best be justified in terms of likely benefits.  Du Bois says that the loss of believing in prospects of human progress is a kind of "death." We don't all agree on exactly what progress consists in, and can leave that for a separate discussion on ethics. But many will agree with Du Bois that 2 impediments to social and personal progress or improvement are racism and social inequality. If one believes these can't be diminished through some kind of human agency or engagement, this "death" of belief in changing external conditions for the better against all odds-- this death of hope-- condemns us not to a healthy acceptance but to an  ill-advised resignation to powerful forces before which we then buckle.  Martin Luther King cited Du Bois' writings as a key influence. It is reflected in the optimism (without evidence in advance) in such speeches as King's "Mountaintop Speech" where he says:

"Like anybody, I would like to live – a long life; longevity has its place. But I'm not concerned about that now. I just want to do God's will. And He's allowed me to go up to the mountain. And I've looked over. And I've seen the Promised Land. I may not get there with you. But I want you to know tonight, that we, as a people, will get to the Promised Land."

Of course we don't know for sure what will happen or if there is any kind of "Promised Land" awaiting the activists being addressed.   But such heartfelt expressions of faith and hope against all odds can (when outcomes are truly unknown) influence attitudes which in turn influence actions which may then affect the outcome in question. So in order to evaluate just which things we should accept as  out of our hands and which we should cultivate the will and courage to change is a much more personal and culturally shaped matter than many advocates of  acceptance-based therapies might imagine.

Personally, I practice mindfulness (though I'm not religious and don't follow any one particular therapeutic ideology) to great benefit. But in my own experience, there is a constructive balance between passionate interest and engagement in our emotional responses on the one hand, and the ability to withstand pain, loss, injury and anger with equanimity on the other. There is something liberating about being able to simply observe or experience the feelings and associated thoughts that come and go in conscious experience without being bent out of shape by them. It's a fine balancing act, and, needless to say, I don't always get it right, and so suffer plenty like most of us. Still, the emphasis on acceptance in recent decades, I think, needs to be better integrated into our cultural and historical legacy which is based so largely on learning ever more about how to modify and improve external as well as internal conditions that  bring suffering about. A healthy synthesis of ancient and modern wisdom has not yet come into being.

What are your thoughts? 

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Related Readings/Resources:

-The "How To Be A Stoic" website is run by philosopher, biologist and modern lifestyle Stoic, Masimo Pigliucci of City Univ. of New York. It includes essays, videos, and links that discuss both ancient stoicism and stoicism for 21st century living. There are also essays that discuss the current joining of Stoicism and Buddhism in a secular context, as discussed above.
 https://howtobeastoic.wordpress.com

--Want to be happy? Then live like a Stoic for a week (published in The Conversation 9/18) Philosopher,  John Sellars, calls attention to the extremely limited conception of the ability of persons to influence or meaningfully shape external conditions in Stoicism.  https://theconversation.com/want-to-be-happy-then-live-like-a-stoic-for-a-week-103117
 

 -- Mindfulness as a Key Construct in Modern Psychotherapy: by  Patricia Bach, Stephen Hayes & Michael Levin. Abstract and article download available here: https://link.springer.com/chapter/10.1007/978-1-4939-2263-5_11

-- Integrating Mindfulness Meditation with Cognitive and Behavioral Therapies: The Challenge of Combining Acceptance-based and Change-Based Strategies: Canadian Journal of Psychiatry: Vol. 50, No. 13: 2005: Mark A Lau,  PhD, Shelly F Mcmain Phd  (Pdf here: https://journals.sagepub.com/doi/pdf/10.1177/070674370505001310



-- The Mindfulness Conspiracy, by Ronald Purser, appeared in the Guardian last year. Professor Purser is also the author of McMindfulness: How Mindfulness Became The New Capitalist Spirituality (Repeater Books; 2019) .  Purser argues in both the book and article that "The fundamental message of the mindfulness movement is that the underlying cause of dissatisfaction and distress is in our own heads," i.e. the ways in which we relate to our own thoughts and feelings rather than social and political forces. "By failing to address collective suffering, and systemic change that might remove it,[teachers of radical acceptance and mindfulness] rob [it] of its real revolutionary potential, reducing it to something banal that keeps people focused on themselves." (from Guardian Article here: https://www.theguardian.com/lifeandstyle/2019/jun/14/the-mindfulness-conspiracy-capitalist-spirituality  ) He is greatly concerned that approaches emphasizing radical acceptance turn subjects inward where they focus on their reactions and responses to events rather than cultivating critical engagement with the events as problems in themselves, thus blunting the drive toward activism in a society that is already far too complacent in the face of major social and interpersonal ills.

--From Conceptualization to Operationalization of Mindfulness: in Handbook of Mindfulness-- Theory, Research and Practice: Guilford Press: 2015 (p. 151-170): J.T. Quaglia, K.W. Brown, et. al.  These researchers emphasize the need for reliable methods to study phenomenological states constitutive of mindfulness. Though I have not addressed methodological issues and problems here, the authors reasonably conclude that "[m]uch work is needed to better understand the nature and expression of mindfulness, as suggested in our review." (p.161) Draft of chapter avail as pdf here: https://pdfs.semanticscholar.org/234b/a4cf66586b4a8f0f4c6bb70b538711ff7f3c.pdf  Excellent work on the problem of operationalizing and empirically studying therapeutic benefits of mindfulness and acceptance in Buddhist-influenced therapies and practices can be found in the work of John D. Dunne and Evan Thompson.

-- Buddhist Philosophy, Phenomenology, and Cognitive Science: Assessing the Dialogue: Evan Thompson avail. at Thompson's website along with other articles relevant to the topic:  https://evanthompson.me/articles/

-- Buddhist Meditation & Neuroscience: Excellent, critical and concise essay by Bernard Faure :
http://files.meetup.com/1502376/FaureB2012.pdf


-- The Problem of Mindfulness by philosopher, Sahanika Ratnayake,  argues that Mindfulness/Radical Acceptance contain problematic metaphysical assumptions about "Reality" and "Self" which can undercut the hard contemplative and analytic work of seeking self-knowledge. Whether or not she is convincing, it is worth considering her critique published on Aeon here: https://aeon.co/essays/mindfulness-is-loaded-with-troubling-metaphysical-assumptions

--Mechanisms of Change in Dialectical Behavior Therapy: Theoretical and Empirical Observations: Journal Of Clinical Psychology, Vol. 62(4), 459-480 (2006) : Thomas R. Lynch, Alexander L. Chapman et. al. https://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.472.9570&rep=rep1&type=pdf

--Hegel's Phenomenology of Spirit  (see Ch. 4; esp.  section 199 on Stoicism) trans. A.V. Miller,

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