For an understanding of the origins of Western psychotherapy, we must start at the beginning with Sigmund Freud. As a neurologist in the late 19th century, he was treating patients who had apparent neurological symptoms, but neurological exam suggested that their symptoms had no physiological basis. Inspired partly by his knowledge of hypnotic phenomena, Freud developed the technique of free association, which he viewed as a tool for investigating a patients psyche. Consider how he would introduce the technique to a new patient: We instruct the patient to put himself into a state of quiet, unreflecting self-observation, and to report to us whatever internal observations he is able to make, taking care not to exclude any of them, whether on the ground that it is toodisagreeableor tooindiscreetto say, or that it is toounimportantorirrelevant, or that it isnonsensicaland need not be said.2 Furthermore, Freud advised the analyst to adopt a mental state of evenly suspended attention while listening to a patient, even referring to it as a meditative attitude.3

Based on the dramatic improvement seen in many patients and on recurrent themes observed in the course of his work, Freud developed a theoretical structure of the human psyche that offered an explanation of mental suffering. He proposed 3 fundamental psychic structures: id, the repository of our primitive animal drives; superego, a repository of morality passed down from society in general and religion in particular; and ego. Ego includes our sense of self and mediates, as best it can, between the basic survival drives, the moral demands of the tradition we grew up in, and the reality we find ourselves in. If egos narrative is sufficiently consistent with the reality situation and with the cultural context in which we live, we appear mentally healthy to ourselves and those around us. The more our narrative is inconsistent with our situation, whether due to unfortunate early childhood programming, other trauma, or to some biochemical dysfunction, the more we will appear to be poorly adjusted, or perhaps ill, and the more mental distress we are likely to experience. This model proved so compelling that, in addition to becoming the bedrock on which our Western psychodynamic theories are built, it has become embedded in our popular culture.

Freud elaborated the technique of free-association into a system of psyche-therapy, or psychotherapy, in which the analyst guides the patient through the experiences that arise in the course of treatment. To grossly oversimplify, the fundamental premise is that mental suffering derives from conflicts that are largely unconscious, and these conflicts can be mitigated by bringing them into consciousness. Later traditions of psychotherapy developed variations in understanding of the nature of intra-psychic conflict and how to deal with it, but in general the focus remains on bringing unconscious conflicts into consciousness and dissecting their meaning.

If you drop the requirement to verbalize ones thoughts (and dispense with the analyst) Freuds instructions are a fair approximation of the basic instructions for mindfulness meditation. This form of meditation, fundamental to all Buddhist teachings, is essentially a technique for observing our thought flow in granular detail without attempting to control it or shape it. As we make a sustained effort to simply observe our thoughts without our habitual judgmental attitude, we begin to develop some degree of equanimity toward our own thought processes. This meditative practice gradually translates into an increased capacity for equanimity as we encounter the vicissitudes of life. The change is experienced subjectively as reduced anxiety, increased emotional stability, increased clarity of mind, and an improved global sense of well-being. These positive results seem to be a natural outcome of the process, and do not depend on adopting any particular belief system or theory of mind.

To understand the Buddhist view of meditation we must again start at the beginning, in this case about 2500 years ago with the life of the Buddha. The Buddha was raised as a prince in Northern India, protected from any knowledge of the suffering inevitably associated with being alive. As he came of age and was confronted with examples of human suffering, he renounced his privileged life and became a wandering yogi, seeking to escape suffering by pursuing the ascetic practices that are still taught in that part of the world. He ultimately abandoned ascetic practices and developed a novel meditative path that led him to what he called enlightenment, which can be understood as a complete understanding of mind and of mental suffering.

When he began to teach he started with 4 simple statements which, translated into English, are known as the Four Noble Truths4:

The meaning of these statements is not self-evident. First, what exactly do we mean by suffering? The teachings discuss the full range of human suffering, summarized by the traditional phrase birth, sickness, old-age, and death. The culture in which Buddhism originated believed in reincarnation as an obvious fact, and the traditional teachings promise that at the culmination of the Buddhist path there is the possibility of escape from the endless cycle of death and rebirththe ultimate escape from suffering. In our role as mental health professionals we do not concern ourselves with speculations about the afterlife, but Buddhist teachings also make it clear that meditation practice is a tool for mitigating mental suffering in this life, which is why we should be interested in understanding it.

The second Noble Truth states that the cause of suffering is ignorance. Ignorance of what? The simple answer is that we are ignorant of the true nature of our own minds. As human beings we all create a complex mental narrative about who we are, what the world is about, and how we fit into it. Buddhist teachers are very comfortable referring to this whole process as ego. Their definition of ego is broader than ours, including all the mental processes and concepts that go into creating and maintaining our experience of ourselves and the world around us. Ego is our natural state, which allows us to navigate the world successfully (or not so successfully, as we in the mental health trade know so well), yet it is also the mechanism through which we unintentionally create suffering for ourselves and those around us.

The third Noble Truth states that there is a way to escape this self-created suffering, and the fourth Noble truth tells us we can achieve this by following the Buddhas instructions, thus replicating his path. The Buddha is presented as a human being who practiced a particular mental discipline that led to specific results, and the assertion is that any person can, at least in principle, attain the same results if they are willing to practice the mental discipline. From this perspective, the Buddhist teachings amount to a psychological system designed to mitigate mental suffering. Interestingly, the Buddha has traditionally been referred to as the ultimate physician, who identified the cause of suffering and pointed out the cure.

Our usual experience of ego is a continuous, more-or-less consistent sense of self. Buddhist psychology asserts that this experience of ego as a solid entity is an illusion. Ego is actually an ongoing process that requires a tremendous amount of mental energy to sustain. The importance of intra-psychic conflict is recognized, but it is felt that there is limited value (and possibly some harm) in focusing too much time and effort on contemplating and analyzing the details of ones personal history. That is, a purely psychotherapeutic approach runs the risk of turning our personal history into an immoveable monument, without necessarily relieving emotional suffering.

Instead, Buddhist psychology focuses, through the lens of meditation, on the moment-to-moment process by which we construct our version of self and the world. When we watch a movie, we are seeing a series of individual frames that are projected on a screen at a speed that gives the illusion of watching real objects and real events. If we stop the projector (or, these days, freeze the data stream), the illusion of motion and reality disappears. We see that the vivid experience of the movie, which perhaps moved us to tears or rage, is just a series of pictures. So it is with ego. We are continuously constructing a series of mental frames that are strung together to give an illusion of a solid self, the world, and a narrative involving our place in the world. The practice of meditation allows us to perceive this reality: that our story about who we are and what the world is about is something we are constantly creating and defending.

Buddhist psychology is not suggesting that we and the world are an illusion, but that our perception of self and the world is an illusion that we are constantly constructing, and it is constantly threatening to fall apart. Whether we are psychologically healthy, just poorly adapted, or suffering from bona fide mental illness, the direct experience of egos insubstantiality resulting from meditation practice can lead to some degree of relaxation of our allegiance to the illusion. This relaxation can reduce the intensity of whatever psychic conflicts we struggle with, regardless of their nature or origin. It may result in an improved ability to relate to the world in an accurate and straightforward manner.5

In summary, psychotherapy and meditation are both widely used for mitigation of mental distress and behavioral dysfunction. There are various theories about the causes of mental distress and about the mechanisms by which these modalities help people, but the reality is that we have no certainty about how it all works, and our methods are at least as much of an art as they are science. This discussion has pointed out that the operational mechanisms of psychotherapy and meditation overlap to some degree, and it is beginning to be accepted that they can be additive in their benefits. If a therapeutic modality seems to have clinical benefit, and if there is no reason to think it can cause significant harm, we are justified in using it even in the absence of rigorous proof of efficacy. It is accordingly reasonable to continue to explore the use of meditation in combination with psychotherapy in the treatment of mental disorders.

However, there is a conundrum at the core of any discussion of psychotherapy and meditation. The underlying theory of mind and of the causes of mental distress offered by the 2 traditions are not only different; they are fundamentally contradictory. The optimal outcome of psychotherapy is a strong and well-functioning ego that can effectively balance our primitive drives with the moral dictates of our society and the reality circumstances of our lives. Meditation practice can be helpful in this endeavor, but the goal of the meditative path as presented by Buddhist psychology is quite different. It is not to strengthen ego or to restructure it to some more favorable configuration, but rather to see through the process of ego altogether in order to systematically reduce its influence on our perception of reality.

But conflicting theories of mind aside, the clinical experience of the meditative tradition suggests that the further one goes on the meditative path, thereby cultivating a reduced intensity of the process we call ego, the more benefit there is in terms of reduction of mental distress, development of emotional stability, and an increased sense of connectedness to the world and to other people. The implications of this observation require an exploration of spirituality and spiritual experiences, which is a larger discussion.

Dr Goderezis a psychopharmacologist and integrative medicine practitioner in private practice.

References

1. Miller J. Mindfulness. Psychiatric Times. December 11, 2019. Accessed November 12, 2020. https://www.psychiatrictimes.com/view/mindfulness

2. Freud S.On the beginning of treatment. In: Strachey J, ed. The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol. 12. The Hogarth Press and the Institute of Psycho-Analysis;1958:123-144.

3. Freud S. Recommendations to Physicians Practicing Psychoanalysis. In: Thompson M. The Truth About Freuds Technique: The Encounter with the Real. New York University Press;1994:145-154.

4. The four noble truths. British Broadcasting Company. Updated November 17, 2009. Accessed December 15, 2020. https://www.bbc.co.uk/religion/religions/buddhism/beliefs/fournobletruths_1.shtml

5. Trungpa, C. The Sanity We Are Born With: A Buddhist Approach to Psychology. Shambhala Publications, Inc.; 2005.

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Psychotherapy and Meditation in the Treatment of Mental Suffering - Psychiatric Times